{ "resourceType": "Bundle", "type": "transaction", "entry": [ { "fullUrl": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "resource": { "resourceType": "Patient", "id": "bd958c64-56b6-f206-b03d-8f4b8a417215", "text": { "status": "generated", "div": "
Generated by Synthea.Version identifier: master-branch-latest-2-g8e7e92c\n . Person seed: 7105486291024734541 Population seed: 0
" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/patient-mothersMaidenName", "valueString": "Graciela518 Badillo851" }, { "url": "http://hl7.org/fhir/StructureDefinition/patient-birthPlace", "valueAddress": { "city": "Caguas", "state": "Puerto Rico", "country": "PR" } }, { "url": "http://synthetichealth.github.io/synthea/disability-adjusted-life-years", "valueDecimal": 1.6165934938317164 }, { "url": "http://synthetichealth.github.io/synthea/quality-adjusted-life-years", "valueDecimal": 47.383406506168288 }, { "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex", "valueCode": "F" }, { "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex", "valueCode": "M" } ], "identifier": [ { "system": "https://github.com/synthetichealth/synthea", "value": "bd958c64-56b6-f206-b03d-8f4b8a417215" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MR", "display": "Medical Record Number" } ], "text": "Medical Record Number" }, "system": "http://hospital.smarthealthit.org", "value": "bd958c64-56b6-f206-b03d-8f4b8a417215" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "SS", "display": "Social Security Number" } ], "text": "Social Security Number" }, "system": "http://hl7.org/fhir/sid/us-ssn", "value": "999-93-6090" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "DL", "display": "Driver's License" } ], "text": "Driver's License" }, "system": "urn:oid:2.16.840.1.113883.4.3.25", "value": "S99913499" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PPN", "display": "Passport Number" } ], "text": "Passport Number" }, "system": "http://standardhealthrecord.org/fhir/StructureDefinition/passportNumber", "value": "X26583229X" } ], "name": [ { "use": "official", "family": "Acosta403", "given": [ "Antonia30" ], "prefix": [ "Mrs." ] }, { "use": "maiden", "family": "Armenta418", "given": [ "Antonia30" ], "prefix": [ "Mrs." ] } ], "telecom": [ { "system": "phone", "value": "555-457-3489", "use": "home" } ], "gender": "female", "birthDate": "1970-09-06", "address": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/geolocation", "extension": [ { "url": "latitude", "valueDecimal": 41.6497330022825 }, { "url": "longitude", "valueDecimal": -71.17511064024423 } ] } ], "line": [ "635 Littel Esplanade Suite 65" ], "city": "Fall River", "state": "Massachusetts", "postalCode": "02790", "country": "US" } ], "maritalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code": "M", "display": "M" } ], "text": "M" }, "multipleBirthBoolean": false, "communication": [ { "language": { "coding": [ { "system": "urn:ietf:bcp:47", "code": "es", "display": "Spanish" } ], "text": "Spanish" } } ] }, "request": { "method": "POST", "url": "Patient" } }, { "fullUrl": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "resource": { "resourceType": "Organization", "id": "a441cbca-6d65-33ff-980c-d8e58235b7e5", "identifier": [ { "system": "https://github.com/synthetichealth/synthea", "value": "a441cbca-6d65-33ff-980c-d8e58235b7e5" } ], "active": true, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/organization-type", "code": "prov", "display": "Healthcare Provider" } ], "text": "Healthcare Provider" } ], "name": "PRIMA CARE PC", "telecom": [ { "system": "phone", "value": "508-676-3292" } ], "address": [ { "line": [ "67 SLADE'S FERRY BOULEVARD" ], "city": "SOMERSET", "state": "MA", "postalCode": "02726-1220", "country": "US" } ] }, "request": { "method": "POST", "url": "Organization" } }, { "fullUrl": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "resource": { "resourceType": "Practitioner", "id": "fadfdb92-e56e-328d-b7d8-3a008e89600c", "identifier": [ { "system": "http://hl7.org/fhir/sid/us-npi", "value": "9999931499" } ], "active": true, "name": [ { "family": "Boyle917", "given": [ "Aubrey96" ], "prefix": [ "Dr." ] } ], "telecom": [ { "system": "email", "value": "Aubrey96.Boyle917@example.com", "use": "work" } ], "address": [ { "line": [ "67 SLADE'S FERRY BOULEVARD" ], "city": "SOMERSET", "state": "MA", "postalCode": "02726-1220", "country": "US" } ], "gender": "female" }, "request": { "method": "POST", "url": "Practitioner" } }, { "fullUrl": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241", "resource": { "resourceType": "Encounter", "id": "6d4fee55-9873-62d4-e129-9c17a1379241", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851", "resource": { "resourceType": "Condition", "id": "9c9b44ea-90e1-aa97-c245-db98b7aa9851", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "59621000", "display": "Hypertension" } ], "text": "Hypertension" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" }, "onsetDateTime": "1989-11-05T02:33:36-07:00", "recordedDate": "1989-11-05T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:aaf49394-d582-216d-98ed-2904e0bfc429", "resource": { "resourceType": "MedicationRequest", "id": "aaf49394-d582-216d-98ed-2904e0bfc429", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" }, "authoredOn": "1989-11-05T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:5a79fbcf-833d-b987-5049-966d07c1d8a5", "resource": { "resourceType": "Claim", "id": "5a79fbcf-833d-b987-5049-966d07c1d8a5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "created": "1989-11-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:aaf49394-d582-216d-98ed-2904e0bfc429" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:aa6d1a80-ea80-8067-925c-f08f02eaef0d", "resource": { "resourceType": "MedicationRequest", "id": "aa6d1a80-ea80-8067-925c-f08f02eaef0d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" }, "authoredOn": "1989-11-05T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b70dcd4b-2e19-1ba3-33f0-f648116e4b76", "resource": { "resourceType": "Claim", "id": "b70dcd4b-2e19-1ba3-33f0-f648116e4b76", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "created": "1989-11-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:aa6d1a80-ea80-8067-925c-f08f02eaef0d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:bccb7920-4d0c-cde9-f80f-1346dd209367", "resource": { "resourceType": "CareTeam", "id": "bccb7920-4d0c-cde9-f80f-1346dd209367", "status": "active", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" }, "period": { "start": "1989-11-05T02:33:36-07:00" }, "participant": [ { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "116154003", "display": "Patient" } ], "text": "Patient" } ], "member": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "223366009", "display": "Healthcare professional (occupation)" } ], "text": "Healthcare professional (occupation)" } ], "member": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "224891009", "display": "Healthcare services (qualifier value)" } ], "text": "Healthcare services (qualifier value)" } ], "member": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } } ], "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "59621000", "display": "Hypertension" } ], "text": "Hypertension" } ], "managingOrganization": [ { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } ] }, "request": { "method": "POST", "url": "CareTeam" } }, { "fullUrl": "urn:uuid:852ba61b-3038-4842-bc2c-9202a31a4abe", "resource": { "resourceType": "CarePlan", "id": "852ba61b-3038-4842-bc2c-9202a31a4abe", "text": { "status": "generated", "div": "
Care Plan for Lifestyle education regarding hypertension.
Activities:
Care plan is meant to treat Hypertension.
" }, "status": "active", "intent": "order", "category": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "443402002", "display": "Lifestyle education regarding hypertension" } ], "text": "Lifestyle education regarding hypertension" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" }, "period": { "start": "1989-11-05T02:33:36-07:00" }, "careTeam": [ { "reference": "urn:uuid:bccb7920-4d0c-cde9-f80f-1346dd209367" } ], "addresses": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "activity": [ { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "386463000", "display": "Prescribed activity/exercise education" } ], "text": "Prescribed activity/exercise education" }, "status": "in-progress", "location": { "display": "PRIMA CARE PC" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "413473000", "display": "Counseling about alcohol consumption" } ], "text": "Counseling about alcohol consumption" }, "status": "in-progress", "location": { "display": "PRIMA CARE PC" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "1151000175103", "display": "Dietary approaches to stop hypertension diet" } ], "text": "Dietary approaches to stop hypertension diet" }, "status": "in-progress", "location": { "display": "PRIMA CARE PC" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "225323000", "display": "Smoking cessation education" } ], "text": "Smoking cessation education" }, "status": "in-progress", "location": { "display": "PRIMA CARE PC" } } } ] }, "request": { "method": "POST", "url": "CarePlan" } }, { "fullUrl": "urn:uuid:8a5e048c-d355-cb9a-cf93-78eda60abad4", "resource": { "resourceType": "Claim", "id": "8a5e048c-d355-cb9a-cf93-78eda60abad4", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "created": "1989-11-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "59621000", "display": "Hypertension" } ], "text": "Hypertension" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6d632f55-6385-5e7f-dc5f-86e9ffafa7df", "resource": { "resourceType": "ExplanationOfBenefit", "id": "6d632f55-6385-5e7f-dc5f-86e9ffafa7df", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "8a5e048c-d355-cb9a-cf93-78eda60abad4" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1989-11-05T02:48:36-07:00", "end": "1990-11-05T02:48:36-07:00" }, "created": "1989-11-05T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:8a5e048c-d355-cb9a-cf93-78eda60abad4" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:6d4fee55-9873-62d4-e129-9c17a1379241" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "59621000", "display": "Hypertension" } ], "text": "Hypertension" }, "servicedPeriod": { "start": "1989-11-05T02:33:36-07:00", "end": "1989-11-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "resource": { "resourceType": "Organization", "id": "ecc51621-0af3-3b35-ac3e-8b1e34022e92", "identifier": [ { "system": "https://github.com/synthetichealth/synthea", "value": "ecc51621-0af3-3b35-ac3e-8b1e34022e92" } ], "active": true, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/organization-type", "code": "prov", "display": "Healthcare Provider" } ], "text": "Healthcare Provider" } ], "name": "SAINT ANNE'S HOSPITAL", "telecom": [ { "system": "phone", "value": "5086745600" } ], "address": [ { "line": [ "795 MIDDLE STREET" ], "city": "FALL RIVER", "state": "MA", "postalCode": "02721", "country": "US" } ] }, "request": { "method": "POST", "url": "Organization" } }, { "fullUrl": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "resource": { "resourceType": "Practitioner", "id": "07cce90b-45bb-3dde-b4a9-b98d846d6033", "identifier": [ { "system": "http://hl7.org/fhir/sid/us-npi", "value": "9999999899" } ], "active": true, "name": [ { "family": "Halvorson124", "given": [ "Carl856" ], "prefix": [ "Dr." ] } ], "telecom": [ { "system": "email", "value": "Carl856.Halvorson124@example.com", "use": "work" } ], "address": [ { "line": [ "795 MIDDLE STREET" ], "city": "FALL RIVER", "state": "MA", "postalCode": "02721", "country": "US" } ], "gender": "male" }, "request": { "method": "POST", "url": "Practitioner" } }, { "fullUrl": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898", "resource": { "resourceType": "Encounter", "id": "a32cbf75-2bfc-1b29-91ea-02fb9f487898", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "EMER" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "183460006", "display": "Obstetric emergency hospital admission" } ], "text": "Obstetric emergency hospital admission" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1990-11-11T02:33:36-07:00", "end": "1990-11-11T03:33:36-07:00" }, "individual": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } } ], "period": { "start": "1990-11-11T02:33:36-07:00", "end": "1990-11-11T03:33:36-07:00" }, "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "72892002", "display": "Normal pregnancy" } ] } ], "serviceProvider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:047284e0-a04b-d9ba-56f6-533ef721b41d", "resource": { "resourceType": "MedicationRequest", "id": "047284e0-a04b-d9ba-56f6-533ef721b41d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898" }, "authoredOn": "1990-11-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:cb61f897-8304-bac6-089c-8f19e5bffa17", "resource": { "resourceType": "Claim", "id": "cb61f897-8304-bac6-089c-8f19e5bffa17", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1990-11-11T02:33:36-07:00", "end": "1990-11-11T03:33:36-07:00" }, "created": "1990-11-11T03:33:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:047284e0-a04b-d9ba-56f6-533ef721b41d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "183460006", "display": "Obstetric emergency hospital admission" } ], "text": "Obstetric emergency hospital admission" }, "encounter": [ { "reference": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6f0a3bf7-9386-5614-010e-80b485ffd91f", "resource": { "resourceType": "MedicationRequest", "id": "6f0a3bf7-9386-5614-010e-80b485ffd91f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898" }, "authoredOn": "1990-11-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:37b8394d-deee-91a6-d226-c9a826f2275d", "resource": { "resourceType": "Claim", "id": "37b8394d-deee-91a6-d226-c9a826f2275d", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1990-11-11T02:33:36-07:00", "end": "1990-11-11T03:33:36-07:00" }, "created": "1990-11-11T03:33:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:6f0a3bf7-9386-5614-010e-80b485ffd91f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "183460006", "display": "Obstetric emergency hospital admission" } ], "text": "Obstetric emergency hospital admission" }, "encounter": [ { "reference": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ae9bb9ab-9270-64f6-c279-1ef4fe92c172", "resource": { "resourceType": "Claim", "id": "ae9bb9ab-9270-64f6-c279-1ef4fe92c172", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1990-11-11T02:33:36-07:00", "end": "1990-11-11T03:33:36-07:00" }, "created": "1990-11-11T03:33:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "183460006", "display": "Obstetric emergency hospital admission" } ], "text": "Obstetric emergency hospital admission" }, "encounter": [ { "reference": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:974783ff-513d-0c82-db95-d037a3f1d397", "resource": { "resourceType": "ExplanationOfBenefit", "id": "974783ff-513d-0c82-db95-d037a3f1d397", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "performer": [ { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Medicaid" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Medicaid" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "ae9bb9ab-9270-64f6-c279-1ef4fe92c172" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1990-11-11T03:33:36-07:00", "end": "1991-11-11T03:33:36-07:00" }, "created": "1990-11-11T03:33:36-07:00", "insurer": { "display": "Medicaid" }, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:ae9bb9ab-9270-64f6-c279-1ef4fe92c172" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Medicaid" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "183460006", "display": "Obstetric emergency hospital admission" } ], "text": "Obstetric emergency hospital admission" }, "servicedPeriod": { "start": "1990-11-11T02:33:36-07:00", "end": "1990-11-11T03:33:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] }, "encounter": [ { "reference": "urn:uuid:a32cbf75-2bfc-1b29-91ea-02fb9f487898" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106", "resource": { "resourceType": "Encounter", "id": "b02bd95f-a9ce-718a-54a2-0e1bcc461106", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1991-11-17T02:33:36-07:00", "end": "1991-11-17T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1991-11-17T02:33:36-07:00", "end": "1991-11-17T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:594be2aa-6e09-ca18-3089-a4109ce07d98", "resource": { "resourceType": "MedicationRequest", "id": "594be2aa-6e09-ca18-3089-a4109ce07d98", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106" }, "authoredOn": "1991-11-17T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:9b63e34b-c39d-b540-ca26-193b7860adaf", "resource": { "resourceType": "Claim", "id": "9b63e34b-c39d-b540-ca26-193b7860adaf", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1991-11-17T02:33:36-07:00", "end": "1991-11-17T02:48:36-07:00" }, "created": "1991-11-17T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:594be2aa-6e09-ca18-3089-a4109ce07d98" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:16bf455e-9e6f-57a9-be02-6cacfa12a055", "resource": { "resourceType": "MedicationRequest", "id": "16bf455e-9e6f-57a9-be02-6cacfa12a055", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106" }, "authoredOn": "1991-11-17T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:ad5ad2f9-a21e-3c4b-9821-e0d5b54d97a5", "resource": { "resourceType": "Claim", "id": "ad5ad2f9-a21e-3c4b-9821-e0d5b54d97a5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1991-11-17T02:33:36-07:00", "end": "1991-11-17T02:48:36-07:00" }, "created": "1991-11-17T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:16bf455e-9e6f-57a9-be02-6cacfa12a055" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:68e0b0c4-c9de-fd79-07a3-8a3aca3d9369", "resource": { "resourceType": "Claim", "id": "68e0b0c4-c9de-fd79-07a3-8a3aca3d9369", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1991-11-17T02:33:36-07:00", "end": "1991-11-17T02:48:36-07:00" }, "created": "1991-11-17T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:1fd0edcb-9b68-fa22-3183-9565dbf75204", "resource": { "resourceType": "ExplanationOfBenefit", "id": "1fd0edcb-9b68-fa22-3183-9565dbf75204", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "68e0b0c4-c9de-fd79-07a3-8a3aca3d9369" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1991-11-17T02:48:36-07:00", "end": "1992-11-17T02:48:36-07:00" }, "created": "1991-11-17T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:68e0b0c4-c9de-fd79-07a3-8a3aca3d9369" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1991-11-17T02:33:36-07:00", "end": "1991-11-17T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:b02bd95f-a9ce-718a-54a2-0e1bcc461106" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92", "resource": { "resourceType": "Encounter", "id": "bf02bc94-82b3-9b53-5a56-781cf750fb92", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1992-11-22T02:33:36-07:00", "end": "1992-11-22T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1992-11-22T02:33:36-07:00", "end": "1992-11-22T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:3ad7a973-7503-edff-43e9-81d774f7db4d", "resource": { "resourceType": "MedicationRequest", "id": "3ad7a973-7503-edff-43e9-81d774f7db4d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92" }, "authoredOn": "1992-11-22T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:f73b621c-5a93-9502-ba77-7f6b65ddcb32", "resource": { "resourceType": "Claim", "id": "f73b621c-5a93-9502-ba77-7f6b65ddcb32", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1992-11-22T02:33:36-07:00", "end": "1992-11-22T02:48:36-07:00" }, "created": "1992-11-22T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:3ad7a973-7503-edff-43e9-81d774f7db4d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b41fe279-7b26-5763-4cd7-660a1d9f35e3", "resource": { "resourceType": "MedicationRequest", "id": "b41fe279-7b26-5763-4cd7-660a1d9f35e3", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92" }, "authoredOn": "1992-11-22T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:96cf1abd-4373-ced9-a6f6-396e8d2cd2cf", "resource": { "resourceType": "Claim", "id": "96cf1abd-4373-ced9-a6f6-396e8d2cd2cf", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1992-11-22T02:33:36-07:00", "end": "1992-11-22T02:48:36-07:00" }, "created": "1992-11-22T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:b41fe279-7b26-5763-4cd7-660a1d9f35e3" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ec6862b8-f39e-fa90-8d4c-a1545712808f", "resource": { "resourceType": "Claim", "id": "ec6862b8-f39e-fa90-8d4c-a1545712808f", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1992-11-22T02:33:36-07:00", "end": "1992-11-22T02:48:36-07:00" }, "created": "1992-11-22T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:80714e6c-ea4d-ba2c-ce13-e2277866e193", "resource": { "resourceType": "ExplanationOfBenefit", "id": "80714e6c-ea4d-ba2c-ce13-e2277866e193", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "ec6862b8-f39e-fa90-8d4c-a1545712808f" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1992-11-22T02:48:36-07:00", "end": "1993-11-22T02:48:36-07:00" }, "created": "1992-11-22T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:ec6862b8-f39e-fa90-8d4c-a1545712808f" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1992-11-22T02:33:36-07:00", "end": "1992-11-22T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:bf02bc94-82b3-9b53-5a56-781cf750fb92" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd", "resource": { "resourceType": "Encounter", "id": "70c6b7e1-588e-750e-5905-2cfc94059efd", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1993-11-28T02:33:36-07:00", "end": "1993-11-28T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1993-11-28T02:33:36-07:00", "end": "1993-11-28T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:efb41235-c8da-71d5-fba9-7ac70b7075cc", "resource": { "resourceType": "MedicationRequest", "id": "efb41235-c8da-71d5-fba9-7ac70b7075cc", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd" }, "authoredOn": "1993-11-28T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:62c459f7-5b67-a227-5def-66c327d1723d", "resource": { "resourceType": "Claim", "id": "62c459f7-5b67-a227-5def-66c327d1723d", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1993-11-28T02:33:36-07:00", "end": "1993-11-28T02:48:36-07:00" }, "created": "1993-11-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:efb41235-c8da-71d5-fba9-7ac70b7075cc" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:524136b4-43e4-e6b0-dc1f-bc34585afd6d", "resource": { "resourceType": "MedicationRequest", "id": "524136b4-43e4-e6b0-dc1f-bc34585afd6d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd" }, "authoredOn": "1993-11-28T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:0f8a21d0-8ce8-0f6a-c7a0-ab538fe8a142", "resource": { "resourceType": "Claim", "id": "0f8a21d0-8ce8-0f6a-c7a0-ab538fe8a142", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1993-11-28T02:33:36-07:00", "end": "1993-11-28T02:48:36-07:00" }, "created": "1993-11-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:524136b4-43e4-e6b0-dc1f-bc34585afd6d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:50b6a69a-8c05-1c1f-aa82-d988cc8da68c", "resource": { "resourceType": "Claim", "id": "50b6a69a-8c05-1c1f-aa82-d988cc8da68c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1993-11-28T02:33:36-07:00", "end": "1993-11-28T02:48:36-07:00" }, "created": "1993-11-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:0b940f9a-aafa-812b-11d2-c0d6eeecf166", "resource": { "resourceType": "ExplanationOfBenefit", "id": "0b940f9a-aafa-812b-11d2-c0d6eeecf166", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "50b6a69a-8c05-1c1f-aa82-d988cc8da68c" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1993-11-28T02:48:36-07:00", "end": "1994-11-28T02:48:36-07:00" }, "created": "1993-11-28T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:50b6a69a-8c05-1c1f-aa82-d988cc8da68c" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1993-11-28T02:33:36-07:00", "end": "1993-11-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:70c6b7e1-588e-750e-5905-2cfc94059efd" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2", "resource": { "resourceType": "Encounter", "id": "fa40152f-1ed6-7486-835c-1295ff07bfe2", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1994-12-04T02:33:36-07:00", "end": "1994-12-04T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1994-12-04T02:33:36-07:00", "end": "1994-12-04T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:9da76155-01b5-8701-f434-116476e72ee4", "resource": { "resourceType": "MedicationRequest", "id": "9da76155-01b5-8701-f434-116476e72ee4", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2" }, "authoredOn": "1994-12-04T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:8f47fcc9-b6fb-0dd0-e13b-165bf35ea94e", "resource": { "resourceType": "Claim", "id": "8f47fcc9-b6fb-0dd0-e13b-165bf35ea94e", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1994-12-04T02:33:36-07:00", "end": "1994-12-04T02:48:36-07:00" }, "created": "1994-12-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:9da76155-01b5-8701-f434-116476e72ee4" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:2104f953-00e8-2048-1114-b586ee63a55d", "resource": { "resourceType": "MedicationRequest", "id": "2104f953-00e8-2048-1114-b586ee63a55d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2" }, "authoredOn": "1994-12-04T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:d8d9ed59-317e-2de8-bb19-3591b7595452", "resource": { "resourceType": "Claim", "id": "d8d9ed59-317e-2de8-bb19-3591b7595452", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1994-12-04T02:33:36-07:00", "end": "1994-12-04T02:48:36-07:00" }, "created": "1994-12-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:2104f953-00e8-2048-1114-b586ee63a55d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:4c1214bb-23e6-709d-f7ba-4ec172752854", "resource": { "resourceType": "Claim", "id": "4c1214bb-23e6-709d-f7ba-4ec172752854", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1994-12-04T02:33:36-07:00", "end": "1994-12-04T02:48:36-07:00" }, "created": "1994-12-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:53902adf-6f67-bf41-d800-65235b4b5494", "resource": { "resourceType": "ExplanationOfBenefit", "id": "53902adf-6f67-bf41-d800-65235b4b5494", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "4c1214bb-23e6-709d-f7ba-4ec172752854" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1994-12-04T02:48:36-07:00", "end": "1995-12-04T02:48:36-07:00" }, "created": "1994-12-04T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:4c1214bb-23e6-709d-f7ba-4ec172752854" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1994-12-04T02:33:36-07:00", "end": "1994-12-04T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:fa40152f-1ed6-7486-835c-1295ff07bfe2" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2", "resource": { "resourceType": "Encounter", "id": "f5f15209-8d88-8465-9a64-b20715e0abb2", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1995-12-10T02:33:36-07:00", "end": "1995-12-10T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1995-12-10T02:33:36-07:00", "end": "1995-12-10T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:b6269bf0-8292-dd4f-2ea0-10ae6791805f", "resource": { "resourceType": "MedicationRequest", "id": "b6269bf0-8292-dd4f-2ea0-10ae6791805f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2" }, "authoredOn": "1995-12-10T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:0ac60790-468d-2545-8f4d-624103f36c42", "resource": { "resourceType": "Claim", "id": "0ac60790-468d-2545-8f4d-624103f36c42", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1995-12-10T02:33:36-07:00", "end": "1995-12-10T02:48:36-07:00" }, "created": "1995-12-10T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:b6269bf0-8292-dd4f-2ea0-10ae6791805f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:850d0838-8519-710c-92b9-bd051bd2211f", "resource": { "resourceType": "MedicationRequest", "id": "850d0838-8519-710c-92b9-bd051bd2211f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2" }, "authoredOn": "1995-12-10T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:db9be9ee-e0d2-beab-532b-dacc5bc5a836", "resource": { "resourceType": "Claim", "id": "db9be9ee-e0d2-beab-532b-dacc5bc5a836", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1995-12-10T02:33:36-07:00", "end": "1995-12-10T02:48:36-07:00" }, "created": "1995-12-10T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:850d0838-8519-710c-92b9-bd051bd2211f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:7592a6f4-52e6-dd74-858f-7aadf6e2b3e9", "resource": { "resourceType": "Claim", "id": "7592a6f4-52e6-dd74-858f-7aadf6e2b3e9", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1995-12-10T02:33:36-07:00", "end": "1995-12-10T02:48:36-07:00" }, "created": "1995-12-10T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:dc2d02a0-5e18-5244-4b08-a9f90eebe7a0", "resource": { "resourceType": "ExplanationOfBenefit", "id": "dc2d02a0-5e18-5244-4b08-a9f90eebe7a0", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "7592a6f4-52e6-dd74-858f-7aadf6e2b3e9" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1995-12-10T02:48:36-07:00", "end": "1996-12-10T02:48:36-07:00" }, "created": "1995-12-10T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:7592a6f4-52e6-dd74-858f-7aadf6e2b3e9" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1995-12-10T02:33:36-07:00", "end": "1995-12-10T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:f5f15209-8d88-8465-9a64-b20715e0abb2" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0", "resource": { "resourceType": "Encounter", "id": "5c84fd72-fd43-bc09-b9be-2865407539f0", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1996-12-15T02:33:36-07:00", "end": "1996-12-15T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1996-12-15T02:33:36-07:00", "end": "1996-12-15T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:2dfff66d-9d38-7c84-7269-5b8bacd8d4fa", "resource": { "resourceType": "MedicationRequest", "id": "2dfff66d-9d38-7c84-7269-5b8bacd8d4fa", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0" }, "authoredOn": "1996-12-15T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:455c0d9e-386c-a94f-be2d-85978fef1911", "resource": { "resourceType": "Claim", "id": "455c0d9e-386c-a94f-be2d-85978fef1911", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1996-12-15T02:33:36-07:00", "end": "1996-12-15T02:48:36-07:00" }, "created": "1996-12-15T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:2dfff66d-9d38-7c84-7269-5b8bacd8d4fa" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:0d989bf8-3d10-8921-7a1f-333d2a71a59f", "resource": { "resourceType": "MedicationRequest", "id": "0d989bf8-3d10-8921-7a1f-333d2a71a59f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0" }, "authoredOn": "1996-12-15T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:184dd46c-3386-2151-4f00-14e8960b8c48", "resource": { "resourceType": "Claim", "id": "184dd46c-3386-2151-4f00-14e8960b8c48", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1996-12-15T02:33:36-07:00", "end": "1996-12-15T02:48:36-07:00" }, "created": "1996-12-15T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:0d989bf8-3d10-8921-7a1f-333d2a71a59f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:53b4e232-d885-9798-9b42-b73a6397124f", "resource": { "resourceType": "Claim", "id": "53b4e232-d885-9798-9b42-b73a6397124f", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1996-12-15T02:33:36-07:00", "end": "1996-12-15T02:48:36-07:00" }, "created": "1996-12-15T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e6e3186c-437f-6c1a-feac-ceafc12ba439", "resource": { "resourceType": "ExplanationOfBenefit", "id": "e6e3186c-437f-6c1a-feac-ceafc12ba439", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "53b4e232-d885-9798-9b42-b73a6397124f" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1996-12-15T02:48:36-07:00", "end": "1997-12-15T02:48:36-07:00" }, "created": "1996-12-15T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:53b4e232-d885-9798-9b42-b73a6397124f" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1996-12-15T02:33:36-07:00", "end": "1996-12-15T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:5c84fd72-fd43-bc09-b9be-2865407539f0" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf", "resource": { "resourceType": "Encounter", "id": "c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1997-12-21T02:33:36-07:00", "end": "1997-12-21T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1997-12-21T02:33:36-07:00", "end": "1997-12-21T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:8fe7883e-89b6-9a3d-44ac-a376ae75d7a8", "resource": { "resourceType": "MedicationRequest", "id": "8fe7883e-89b6-9a3d-44ac-a376ae75d7a8", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf" }, "authoredOn": "1997-12-21T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:be661d2c-b3c3-a5d1-bc48-180d7829f6c7", "resource": { "resourceType": "Claim", "id": "be661d2c-b3c3-a5d1-bc48-180d7829f6c7", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1997-12-21T02:33:36-07:00", "end": "1997-12-21T02:48:36-07:00" }, "created": "1997-12-21T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:8fe7883e-89b6-9a3d-44ac-a376ae75d7a8" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:eccf291b-476f-914e-8265-ce7bbc272401", "resource": { "resourceType": "MedicationRequest", "id": "eccf291b-476f-914e-8265-ce7bbc272401", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf" }, "authoredOn": "1997-12-21T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:7ab1e3f7-70f9-2fde-c792-8c00135b0d82", "resource": { "resourceType": "Claim", "id": "7ab1e3f7-70f9-2fde-c792-8c00135b0d82", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1997-12-21T02:33:36-07:00", "end": "1997-12-21T02:48:36-07:00" }, "created": "1997-12-21T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:eccf291b-476f-914e-8265-ce7bbc272401" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:23eb1549-df70-2867-3a3e-f8327bb7bdd1", "resource": { "resourceType": "Claim", "id": "23eb1549-df70-2867-3a3e-f8327bb7bdd1", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1997-12-21T02:33:36-07:00", "end": "1997-12-21T02:48:36-07:00" }, "created": "1997-12-21T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Anthem" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:38deec87-f321-8957-886c-9f78da01df31", "resource": { "resourceType": "ExplanationOfBenefit", "id": "38deec87-f321-8957-886c-9f78da01df31", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Anthem" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Anthem" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "23eb1549-df70-2867-3a3e-f8327bb7bdd1" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1997-12-21T02:48:36-07:00", "end": "1998-12-21T02:48:36-07:00" }, "created": "1997-12-21T02:48:36-07:00", "insurer": { "display": "Anthem" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:23eb1549-df70-2867-3a3e-f8327bb7bdd1" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Anthem" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1997-12-21T02:33:36-07:00", "end": "1997-12-21T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:c1d006e5-bb59-cfa7-8926-0aa34aa4dfaf" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a", "resource": { "resourceType": "Encounter", "id": "0c078aa8-9f53-54a4-8804-28c034b5514a", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "1998-12-27T02:33:36-07:00", "end": "1998-12-27T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "1998-12-27T02:33:36-07:00", "end": "1998-12-27T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:8eea10f7-ed5e-480e-c96c-b26964eaf509", "resource": { "resourceType": "MedicationRequest", "id": "8eea10f7-ed5e-480e-c96c-b26964eaf509", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a" }, "authoredOn": "1998-12-27T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:c74d492a-4a65-65a7-e507-8a802374d2c3", "resource": { "resourceType": "Claim", "id": "c74d492a-4a65-65a7-e507-8a802374d2c3", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1998-12-27T02:33:36-07:00", "end": "1998-12-27T02:48:36-07:00" }, "created": "1998-12-27T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:8eea10f7-ed5e-480e-c96c-b26964eaf509" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:0faa3ab0-9edf-0094-5eb2-b632a413fea0", "resource": { "resourceType": "MedicationRequest", "id": "0faa3ab0-9edf-0094-5eb2-b632a413fea0", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a" }, "authoredOn": "1998-12-27T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:dc804152-081b-5215-65a7-fc80a0fddf36", "resource": { "resourceType": "Claim", "id": "dc804152-081b-5215-65a7-fc80a0fddf36", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1998-12-27T02:33:36-07:00", "end": "1998-12-27T02:48:36-07:00" }, "created": "1998-12-27T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:0faa3ab0-9edf-0094-5eb2-b632a413fea0" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b8bb78f3-9430-dac2-da35-6831f41cba74", "resource": { "resourceType": "Claim", "id": "b8bb78f3-9430-dac2-da35-6831f41cba74", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "1998-12-27T02:33:36-07:00", "end": "1998-12-27T02:48:36-07:00" }, "created": "1998-12-27T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:1ef592ba-c877-1416-e927-7505ebd1acc1", "resource": { "resourceType": "ExplanationOfBenefit", "id": "1ef592ba-c877-1416-e927-7505ebd1acc1", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Medicaid" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Medicaid" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "b8bb78f3-9430-dac2-da35-6831f41cba74" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "1998-12-27T02:48:36-07:00", "end": "1999-12-27T02:48:36-07:00" }, "created": "1998-12-27T02:48:36-07:00", "insurer": { "display": "Medicaid" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:b8bb78f3-9430-dac2-da35-6831f41cba74" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Medicaid" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "1998-12-27T02:33:36-07:00", "end": "1998-12-27T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:0c078aa8-9f53-54a4-8804-28c034b5514a" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64", "resource": { "resourceType": "Encounter", "id": "e1466754-f63c-3631-b58c-5c311cbc6e64", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2000-01-02T02:33:36-07:00", "end": "2000-01-02T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2000-01-02T02:33:36-07:00", "end": "2000-01-02T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:a6dada93-68eb-15d9-27fb-3404db6f8b25", "resource": { "resourceType": "MedicationRequest", "id": "a6dada93-68eb-15d9-27fb-3404db6f8b25", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64" }, "authoredOn": "2000-01-02T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:2adde43a-88a2-5ec1-3600-d6f0fe3df034", "resource": { "resourceType": "Claim", "id": "2adde43a-88a2-5ec1-3600-d6f0fe3df034", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2000-01-02T02:33:36-07:00", "end": "2000-01-02T02:48:36-07:00" }, "created": "2000-01-02T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:a6dada93-68eb-15d9-27fb-3404db6f8b25" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Blue Cross Blue Shield" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f4a8d21b-e48e-ae0e-27ff-c5a962b8f44a", "resource": { "resourceType": "MedicationRequest", "id": "f4a8d21b-e48e-ae0e-27ff-c5a962b8f44a", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64" }, "authoredOn": "2000-01-02T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:22ed1761-3d6d-5116-5eef-78a5b2443e0e", "resource": { "resourceType": "Claim", "id": "22ed1761-3d6d-5116-5eef-78a5b2443e0e", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2000-01-02T02:33:36-07:00", "end": "2000-01-02T02:48:36-07:00" }, "created": "2000-01-02T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:f4a8d21b-e48e-ae0e-27ff-c5a962b8f44a" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Blue Cross Blue Shield" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:1bdb3d29-a2b5-ac6a-613a-d4d167972cb9", "resource": { "resourceType": "Claim", "id": "1bdb3d29-a2b5-ac6a-613a-d4d167972cb9", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2000-01-02T02:33:36-07:00", "end": "2000-01-02T02:48:36-07:00" }, "created": "2000-01-02T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Blue Cross Blue Shield" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d86fc858-5043-8f16-fdc4-b77a6a59a6fc", "resource": { "resourceType": "ExplanationOfBenefit", "id": "d86fc858-5043-8f16-fdc4-b77a6a59a6fc", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Blue Cross Blue Shield" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Blue Cross Blue Shield" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "1bdb3d29-a2b5-ac6a-613a-d4d167972cb9" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2000-01-02T02:48:36-07:00", "end": "2001-01-02T02:48:36-07:00" }, "created": "2000-01-02T02:48:36-07:00", "insurer": { "display": "Blue Cross Blue Shield" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:1bdb3d29-a2b5-ac6a-613a-d4d167972cb9" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Blue Cross Blue Shield" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2000-01-02T02:33:36-07:00", "end": "2000-01-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:e1466754-f63c-3631-b58c-5c311cbc6e64" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420", "resource": { "resourceType": "Encounter", "id": "7a4828a7-873c-f626-c914-cd8f20847420", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2001-01-07T02:33:36-07:00", "end": "2001-01-07T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2001-01-07T02:33:36-07:00", "end": "2001-01-07T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:a6ef0503-2f92-046c-3a1e-2a09650b836f", "resource": { "resourceType": "MedicationRequest", "id": "a6ef0503-2f92-046c-3a1e-2a09650b836f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420" }, "authoredOn": "2001-01-07T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:12b07912-c01e-3281-0d34-4fa8dadac5d2", "resource": { "resourceType": "Claim", "id": "12b07912-c01e-3281-0d34-4fa8dadac5d2", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2001-01-07T02:33:36-07:00", "end": "2001-01-07T02:48:36-07:00" }, "created": "2001-01-07T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:a6ef0503-2f92-046c-3a1e-2a09650b836f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:dcfc1819-165d-fb08-1bda-a1e3e8947dbb", "resource": { "resourceType": "MedicationRequest", "id": "dcfc1819-165d-fb08-1bda-a1e3e8947dbb", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420" }, "authoredOn": "2001-01-07T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1a63c8fd-6c1c-8739-8265-711ac70a2944", "resource": { "resourceType": "Claim", "id": "1a63c8fd-6c1c-8739-8265-711ac70a2944", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2001-01-07T02:33:36-07:00", "end": "2001-01-07T02:48:36-07:00" }, "created": "2001-01-07T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:dcfc1819-165d-fb08-1bda-a1e3e8947dbb" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b1a3cfa6-1db1-1f9d-2823-160e50576a98", "resource": { "resourceType": "Claim", "id": "b1a3cfa6-1db1-1f9d-2823-160e50576a98", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2001-01-07T02:33:36-07:00", "end": "2001-01-07T02:48:36-07:00" }, "created": "2001-01-07T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Medicaid" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ab11978b-1e9c-6516-af36-d0922a189292", "resource": { "resourceType": "ExplanationOfBenefit", "id": "ab11978b-1e9c-6516-af36-d0922a189292", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Medicaid" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Medicaid" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "b1a3cfa6-1db1-1f9d-2823-160e50576a98" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2001-01-07T02:48:36-07:00", "end": "2002-01-07T02:48:36-07:00" }, "created": "2001-01-07T02:48:36-07:00", "insurer": { "display": "Medicaid" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:b1a3cfa6-1db1-1f9d-2823-160e50576a98" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Medicaid" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2001-01-07T02:33:36-07:00", "end": "2001-01-07T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:7a4828a7-873c-f626-c914-cd8f20847420" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3", "resource": { "resourceType": "Encounter", "id": "31941389-b8d1-9622-8db6-5d81e0acb1a3", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2002-01-13T02:33:36-07:00", "end": "2002-01-13T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2002-01-13T02:33:36-07:00", "end": "2002-01-13T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d321c6f7-f4f8-6460-e536-77f31e0d52f8", "resource": { "resourceType": "MedicationRequest", "id": "d321c6f7-f4f8-6460-e536-77f31e0d52f8", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3" }, "authoredOn": "2002-01-13T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:69edcbf8-03b8-1e52-5801-b9aa42c445db", "resource": { "resourceType": "Claim", "id": "69edcbf8-03b8-1e52-5801-b9aa42c445db", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2002-01-13T02:33:36-07:00", "end": "2002-01-13T02:48:36-07:00" }, "created": "2002-01-13T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:d321c6f7-f4f8-6460-e536-77f31e0d52f8" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:702e6b10-69e5-3163-0ef8-8ed1dd2a1958", "resource": { "resourceType": "MedicationRequest", "id": "702e6b10-69e5-3163-0ef8-8ed1dd2a1958", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3" }, "authoredOn": "2002-01-13T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1bfd17f9-0776-482c-c7d0-30e9409e2e24", "resource": { "resourceType": "Claim", "id": "1bfd17f9-0776-482c-c7d0-30e9409e2e24", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2002-01-13T02:33:36-07:00", "end": "2002-01-13T02:48:36-07:00" }, "created": "2002-01-13T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:702e6b10-69e5-3163-0ef8-8ed1dd2a1958" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:5878e7b5-53b6-88f2-b451-dcfb6e1382ba", "resource": { "resourceType": "Claim", "id": "5878e7b5-53b6-88f2-b451-dcfb6e1382ba", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2002-01-13T02:33:36-07:00", "end": "2002-01-13T02:48:36-07:00" }, "created": "2002-01-13T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b251d3e7-1c7e-b873-3f9a-b912975b9dc7", "resource": { "resourceType": "ExplanationOfBenefit", "id": "b251d3e7-1c7e-b873-3f9a-b912975b9dc7", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "5878e7b5-53b6-88f2-b451-dcfb6e1382ba" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2002-01-13T02:48:36-07:00", "end": "2003-01-13T02:48:36-07:00" }, "created": "2002-01-13T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:5878e7b5-53b6-88f2-b451-dcfb6e1382ba" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2002-01-13T02:33:36-07:00", "end": "2002-01-13T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:31941389-b8d1-9622-8db6-5d81e0acb1a3" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8", "resource": { "resourceType": "Encounter", "id": "59745f5d-8297-44e2-3970-1ced694b3ac8", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2003-01-19T02:33:36-07:00", "end": "2003-01-19T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2003-01-19T02:33:36-07:00", "end": "2003-01-19T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:04f26ff1-df01-7d2e-28c3-31f07c6a9cf0", "resource": { "resourceType": "MedicationRequest", "id": "04f26ff1-df01-7d2e-28c3-31f07c6a9cf0", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8" }, "authoredOn": "2003-01-19T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:7abf7193-4406-788a-88ba-1e5a7a9dac4e", "resource": { "resourceType": "Claim", "id": "7abf7193-4406-788a-88ba-1e5a7a9dac4e", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2003-01-19T02:33:36-07:00", "end": "2003-01-19T02:48:36-07:00" }, "created": "2003-01-19T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:04f26ff1-df01-7d2e-28c3-31f07c6a9cf0" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b7a3169d-bdce-7229-d644-2fbcc04e412f", "resource": { "resourceType": "MedicationRequest", "id": "b7a3169d-bdce-7229-d644-2fbcc04e412f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8" }, "authoredOn": "2003-01-19T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:c6274971-a92b-9d49-aaa1-b8a9336541c0", "resource": { "resourceType": "Claim", "id": "c6274971-a92b-9d49-aaa1-b8a9336541c0", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2003-01-19T02:33:36-07:00", "end": "2003-01-19T02:48:36-07:00" }, "created": "2003-01-19T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:b7a3169d-bdce-7229-d644-2fbcc04e412f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:a27b2343-086f-b573-b09f-95aa500575f8", "resource": { "resourceType": "Claim", "id": "a27b2343-086f-b573-b09f-95aa500575f8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2003-01-19T02:33:36-07:00", "end": "2003-01-19T02:48:36-07:00" }, "created": "2003-01-19T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:8e8dfc2c-cdd3-cf00-49d1-8d73bcc535b4", "resource": { "resourceType": "ExplanationOfBenefit", "id": "8e8dfc2c-cdd3-cf00-49d1-8d73bcc535b4", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "a27b2343-086f-b573-b09f-95aa500575f8" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2003-01-19T02:48:36-07:00", "end": "2004-01-19T02:48:36-07:00" }, "created": "2003-01-19T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:a27b2343-086f-b573-b09f-95aa500575f8" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2003-01-19T02:33:36-07:00", "end": "2003-01-19T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:59745f5d-8297-44e2-3970-1ced694b3ac8" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523", "resource": { "resourceType": "Encounter", "id": "c242e88b-856e-2bdf-e616-005c34525523", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2004-01-25T02:33:36-07:00", "end": "2004-01-25T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2004-01-25T02:33:36-07:00", "end": "2004-01-25T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d0ce3789-862a-1894-c560-9b09fb3df363", "resource": { "resourceType": "MedicationRequest", "id": "d0ce3789-862a-1894-c560-9b09fb3df363", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523" }, "authoredOn": "2004-01-25T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:a353c6f8-05f2-1583-7171-006d14640f6c", "resource": { "resourceType": "Claim", "id": "a353c6f8-05f2-1583-7171-006d14640f6c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2004-01-25T02:33:36-07:00", "end": "2004-01-25T02:48:36-07:00" }, "created": "2004-01-25T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:d0ce3789-862a-1894-c560-9b09fb3df363" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d2f64061-c97c-d06e-3df5-9eedbf3d072d", "resource": { "resourceType": "MedicationRequest", "id": "d2f64061-c97c-d06e-3df5-9eedbf3d072d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523" }, "authoredOn": "2004-01-25T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:16f4935d-2031-b23b-88ea-24e6afa564f4", "resource": { "resourceType": "Claim", "id": "16f4935d-2031-b23b-88ea-24e6afa564f4", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2004-01-25T02:33:36-07:00", "end": "2004-01-25T02:48:36-07:00" }, "created": "2004-01-25T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:d2f64061-c97c-d06e-3df5-9eedbf3d072d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:97744121-e8a2-04fa-fe04-4855b08a9f12", "resource": { "resourceType": "Claim", "id": "97744121-e8a2-04fa-fe04-4855b08a9f12", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2004-01-25T02:33:36-07:00", "end": "2004-01-25T02:48:36-07:00" }, "created": "2004-01-25T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:486c4d60-365f-f627-6df8-d5ccb8b1adbe", "resource": { "resourceType": "ExplanationOfBenefit", "id": "486c4d60-365f-f627-6df8-d5ccb8b1adbe", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "97744121-e8a2-04fa-fe04-4855b08a9f12" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2004-01-25T02:48:36-07:00", "end": "2005-01-25T02:48:36-07:00" }, "created": "2004-01-25T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:97744121-e8a2-04fa-fe04-4855b08a9f12" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2004-01-25T02:33:36-07:00", "end": "2004-01-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:c242e88b-856e-2bdf-e616-005c34525523" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39", "resource": { "resourceType": "Encounter", "id": "130de84d-1ecc-f92b-b88e-3aacbcb69b39", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2005-01-30T02:33:36-07:00", "end": "2005-01-30T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2005-01-30T02:33:36-07:00", "end": "2005-01-30T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:f44525fd-340d-4e28-2610-fe92f9b27233", "resource": { "resourceType": "MedicationRequest", "id": "f44525fd-340d-4e28-2610-fe92f9b27233", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39" }, "authoredOn": "2005-01-30T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:55bd56f7-53e6-b0f5-5d11-e010f2e72e6d", "resource": { "resourceType": "Claim", "id": "55bd56f7-53e6-b0f5-5d11-e010f2e72e6d", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2005-01-30T02:33:36-07:00", "end": "2005-01-30T02:48:36-07:00" }, "created": "2005-01-30T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:f44525fd-340d-4e28-2610-fe92f9b27233" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9979d604-f82c-7467-db9c-889fb0a7939e", "resource": { "resourceType": "MedicationRequest", "id": "9979d604-f82c-7467-db9c-889fb0a7939e", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39" }, "authoredOn": "2005-01-30T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:ffcd5f4a-f7bb-8dd2-aa91-0bd4e1ab0e9a", "resource": { "resourceType": "Claim", "id": "ffcd5f4a-f7bb-8dd2-aa91-0bd4e1ab0e9a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2005-01-30T02:33:36-07:00", "end": "2005-01-30T02:48:36-07:00" }, "created": "2005-01-30T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:9979d604-f82c-7467-db9c-889fb0a7939e" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f987449b-362d-54cf-85b9-a5d2a05c04b1", "resource": { "resourceType": "Claim", "id": "f987449b-362d-54cf-85b9-a5d2a05c04b1", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2005-01-30T02:33:36-07:00", "end": "2005-01-30T02:48:36-07:00" }, "created": "2005-01-30T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6dcf1306-b58f-fb3e-3ed9-6d00bdb13555", "resource": { "resourceType": "ExplanationOfBenefit", "id": "6dcf1306-b58f-fb3e-3ed9-6d00bdb13555", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "f987449b-362d-54cf-85b9-a5d2a05c04b1" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2005-01-30T02:48:36-07:00", "end": "2006-01-30T02:48:36-07:00" }, "created": "2005-01-30T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:f987449b-362d-54cf-85b9-a5d2a05c04b1" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2005-01-30T02:33:36-07:00", "end": "2005-01-30T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:130de84d-1ecc-f92b-b88e-3aacbcb69b39" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff", "resource": { "resourceType": "Encounter", "id": "219c7db6-b4e0-018e-fc87-eafb690911ff", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052", "resource": { "resourceType": "Condition", "id": "ff42a1fb-5fee-2b3b-9a78-d0ccd2883052", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "44054006", "display": "Diabetes" } ], "text": "Diabetes" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" }, "onsetDateTime": "2006-02-05T02:33:36-07:00", "recordedDate": "2006-02-05T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:8462f8a3-3611-b798-cf0e-3a5e59ea3a7f", "resource": { "resourceType": "Condition", "id": "8462f8a3-3611-b798-cf0e-3a5e59ea3a7f", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "271737000", "display": "Anemia (disorder)" } ], "text": "Anemia (disorder)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" }, "onsetDateTime": "2006-02-05T02:33:36-07:00", "recordedDate": "2006-02-05T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:bd0d888d-dcbe-e2ce-7507-352a00c701eb", "resource": { "resourceType": "MedicationRequest", "id": "bd0d888d-dcbe-e2ce-7507-352a00c701eb", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" }, "authoredOn": "2006-02-05T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:61192e7f-fe15-f324-0703-7e331343980f", "resource": { "resourceType": "Claim", "id": "61192e7f-fe15-f324-0703-7e331343980f", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:bd0d888d-dcbe-e2ce-7507-352a00c701eb" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6e180e39-09ff-5680-c8b0-ab39574191a0", "resource": { "resourceType": "MedicationRequest", "id": "6e180e39-09ff-5680-c8b0-ab39574191a0", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" }, "authoredOn": "2006-02-05T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:d1f980c1-e6ad-942d-8604-3327fe9cd7ef", "resource": { "resourceType": "Claim", "id": "d1f980c1-e6ad-942d-8604-3327fe9cd7ef", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:6e180e39-09ff-5680-c8b0-ab39574191a0" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d9ac1408-8ba6-16dd-2f29-09d1272aac91", "resource": { "resourceType": "CareTeam", "id": "d9ac1408-8ba6-16dd-2f29-09d1272aac91", "status": "active", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" }, "period": { "start": "2006-02-05T02:33:36-07:00" }, "participant": [ { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "116154003", "display": "Patient" } ], "text": "Patient" } ], "member": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "223366009", "display": "Healthcare professional (occupation)" } ], "text": "Healthcare professional (occupation)" } ], "member": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "224891009", "display": "Healthcare services (qualifier value)" } ], "text": "Healthcare services (qualifier value)" } ], "member": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } } ], "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "44054006", "display": "Diabetes" } ], "text": "Diabetes" } ], "managingOrganization": [ { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } ] }, "request": { "method": "POST", "url": "CareTeam" } }, { "fullUrl": "urn:uuid:61276fb0-24fe-12f2-cefe-c2dbd932c342", "resource": { "resourceType": "CarePlan", "id": "61276fb0-24fe-12f2-cefe-c2dbd932c342", "text": { "status": "generated", "div": "
Care Plan for Diabetes self management plan.
Activities:
Care plan is meant to treat Diabetes.
" }, "status": "active", "intent": "order", "category": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698360004", "display": "Diabetes self management plan" } ], "text": "Diabetes self management plan" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" }, "period": { "start": "2006-02-05T02:33:36-07:00" }, "careTeam": [ { "reference": "urn:uuid:d9ac1408-8ba6-16dd-2f29-09d1272aac91" } ], "addresses": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ], "activity": [ { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "160670007", "display": "Diabetic diet" } ], "text": "Diabetic diet" }, "status": "in-progress", "location": { "display": "PRIMA CARE PC" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "229065009", "display": "Exercise therapy" } ], "text": "Exercise therapy" }, "status": "in-progress", "location": { "display": "PRIMA CARE PC" } } } ] }, "request": { "method": "POST", "url": "CarePlan" } }, { "fullUrl": "urn:uuid:906f3321-3389-0cf8-8573-6ffd4d459606", "resource": { "resourceType": "Claim", "id": "906f3321-3389-0cf8-8573-6ffd4d459606", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:8462f8a3-3611-b798-cf0e-3a5e59ea3a7f" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "44054006", "display": "Diabetes" } ], "text": "Diabetes" } }, { "sequence": 3, "diagnosisSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "271737000", "display": "Anemia (disorder)" } ], "text": "Anemia (disorder)" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f09d20e5-6e8a-c476-dde0-ae664ae15791", "resource": { "resourceType": "ExplanationOfBenefit", "id": "f09d20e5-6e8a-c476-dde0-ae664ae15791", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "906f3321-3389-0cf8-8573-6ffd4d459606" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2006-02-05T02:48:36-07:00", "end": "2007-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:906f3321-3389-0cf8-8573-6ffd4d459606" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:8462f8a3-3611-b798-cf0e-3a5e59ea3a7f" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:219c7db6-b4e0-018e-fc87-eafb690911ff" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "44054006", "display": "Diabetes" } ], "text": "Diabetes" }, "servicedPeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } }, { "sequence": 3, "diagnosisSequence": [ 2 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "271737000", "display": "Anemia (disorder)" } ], "text": "Anemia (disorder)" }, "servicedPeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:16122b36-3c56-86e6-4f27-977bcc8927e8", "resource": { "resourceType": "Encounter", "id": "16122b36-3c56-86e6-4f27-977bcc8927e8", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "185347001", "display": "Encounter for problem" } ], "text": "Encounter for problem" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } } ], "period": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "271737000", "display": "Anemia (disorder)" } ] } ], "serviceProvider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:16d335d1-f562-2f00-26ce-88cbca086f47", "resource": { "resourceType": "MedicationRequest", "id": "16d335d1-f562-2f00-26ce-88cbca086f47", "status": "active", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310325", "display": "ferrous sulfate 325 MG Oral Tablet" } ], "text": "ferrous sulfate 325 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:16122b36-3c56-86e6-4f27-977bcc8927e8" }, "authoredOn": "2006-02-05T03:49:36-07:00", "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:af0fa110-e0f3-543e-fd1e-f74040d68345", "resource": { "resourceType": "Claim", "id": "af0fa110-e0f3-543e-fd1e-f74040d68345", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:16d335d1-f562-2f00-26ce-88cbca086f47" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185347001", "display": "Encounter for problem" } ], "text": "Encounter for problem" }, "encounter": [ { "reference": "urn:uuid:16122b36-3c56-86e6-4f27-977bcc8927e8" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:cf1cf238-c7f1-6e9c-f570-c18cdb2cfa35", "resource": { "resourceType": "Claim", "id": "cf1cf238-c7f1-6e9c-f570-c18cdb2cfa35", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185347001", "display": "Encounter for problem" } ], "text": "Encounter for problem" }, "encounter": [ { "reference": "urn:uuid:16122b36-3c56-86e6-4f27-977bcc8927e8" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:67142d10-f1cf-f2a0-0eb3-b5ef22a550cf", "resource": { "resourceType": "ExplanationOfBenefit", "id": "67142d10-f1cf-f2a0-0eb3-b5ef22a550cf", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "performer": [ { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "cf1cf238-c7f1-6e9c-f570-c18cdb2cfa35" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2006-02-05T02:48:36-07:00", "end": "2007-02-05T02:48:36-07:00" }, "created": "2006-02-05T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:cf1cf238-c7f1-6e9c-f570-c18cdb2cfa35" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185347001", "display": "Encounter for problem" } ], "text": "Encounter for problem" }, "servicedPeriod": { "start": "2006-02-05T02:33:36-07:00", "end": "2006-02-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:16122b36-3c56-86e6-4f27-977bcc8927e8" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610", "resource": { "resourceType": "Encounter", "id": "81f2b2b3-7d2f-a999-2c1f-3f181158c610", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:1de9b9a5-ea06-ca2b-fffb-6c654ec7915e", "resource": { "resourceType": "Condition", "id": "1de9b9a5-ea06-ca2b-fffb-6c654ec7915e", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "302870006", "display": "Hypertriglyceridemia (disorder)" } ], "text": "Hypertriglyceridemia (disorder)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" }, "onsetDateTime": "2007-02-11T02:33:36-07:00", "recordedDate": "2007-02-11T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:f6a4b32b-ba13-950a-d1f5-c953127ad6ee", "resource": { "resourceType": "Condition", "id": "f6a4b32b-ba13-950a-d1f5-c953127ad6ee", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "237602007", "display": "Metabolic syndrome X (disorder)" } ], "text": "Metabolic syndrome X (disorder)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" }, "onsetDateTime": "2007-02-11T02:33:36-07:00", "recordedDate": "2007-02-11T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:8a0031d6-ae55-7a04-1aa7-b82fc7a6fe6a", "resource": { "resourceType": "MedicationRequest", "id": "8a0031d6-ae55-7a04-1aa7-b82fc7a6fe6a", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" }, "authoredOn": "2007-02-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b5302562-0985-0945-f61b-4415494a4fcd", "resource": { "resourceType": "Claim", "id": "b5302562-0985-0945-f61b-4415494a4fcd", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "created": "2007-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:8a0031d6-ae55-7a04-1aa7-b82fc7a6fe6a" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:28ed7fbc-9043-34d6-8a76-9e132f9dfa91", "resource": { "resourceType": "MedicationRequest", "id": "28ed7fbc-9043-34d6-8a76-9e132f9dfa91", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" }, "authoredOn": "2007-02-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:bc309768-b43c-a666-2dc5-b9aadc6deb0c", "resource": { "resourceType": "Claim", "id": "bc309768-b43c-a666-2dc5-b9aadc6deb0c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "created": "2007-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:28ed7fbc-9043-34d6-8a76-9e132f9dfa91" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:077edb06-6806-2d4d-895c-bc830e4e1217", "resource": { "resourceType": "Claim", "id": "077edb06-6806-2d4d-895c-bc830e4e1217", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "created": "2007-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:1de9b9a5-ea06-ca2b-fffb-6c654ec7915e" } }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:f6a4b32b-ba13-950a-d1f5-c953127ad6ee" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "302870006", "display": "Hypertriglyceridemia (disorder)" } ], "text": "Hypertriglyceridemia (disorder)" } }, { "sequence": 3, "diagnosisSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "237602007", "display": "Metabolic syndrome X (disorder)" } ], "text": "Metabolic syndrome X (disorder)" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:3427aa28-c243-88cd-59c5-3556f8ea02f0", "resource": { "resourceType": "ExplanationOfBenefit", "id": "3427aa28-c243-88cd-59c5-3556f8ea02f0", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "077edb06-6806-2d4d-895c-bc830e4e1217" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2007-02-11T02:48:36-07:00", "end": "2008-02-11T02:48:36-07:00" }, "created": "2007-02-11T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:077edb06-6806-2d4d-895c-bc830e4e1217" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:1de9b9a5-ea06-ca2b-fffb-6c654ec7915e" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:f6a4b32b-ba13-950a-d1f5-c953127ad6ee" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:81f2b2b3-7d2f-a999-2c1f-3f181158c610" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "302870006", "display": "Hypertriglyceridemia (disorder)" } ], "text": "Hypertriglyceridemia (disorder)" }, "servicedPeriod": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } }, { "sequence": 3, "diagnosisSequence": [ 2 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "237602007", "display": "Metabolic syndrome X (disorder)" } ], "text": "Metabolic syndrome X (disorder)" }, "servicedPeriod": { "start": "2007-02-11T02:33:36-07:00", "end": "2007-02-11T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61", "resource": { "resourceType": "Encounter", "id": "24356772-97fa-129a-12d3-4e2c8d160b61", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2008-02-17T02:33:36-07:00", "end": "2008-02-17T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2008-02-17T02:33:36-07:00", "end": "2008-02-17T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:f69517de-1405-0d9c-6f9f-6dcc7c172a21", "resource": { "resourceType": "MedicationRequest", "id": "f69517de-1405-0d9c-6f9f-6dcc7c172a21", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61" }, "authoredOn": "2008-02-17T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:f0482359-94b9-9cf2-50f3-fc6df9098779", "resource": { "resourceType": "Claim", "id": "f0482359-94b9-9cf2-50f3-fc6df9098779", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2008-02-17T02:33:36-07:00", "end": "2008-02-17T02:48:36-07:00" }, "created": "2008-02-17T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:f69517de-1405-0d9c-6f9f-6dcc7c172a21" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:54990a97-8d24-a73a-b986-3fb38fa3542a", "resource": { "resourceType": "MedicationRequest", "id": "54990a97-8d24-a73a-b986-3fb38fa3542a", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61" }, "authoredOn": "2008-02-17T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1c852624-1d2d-2a0f-e14c-81d9030c328d", "resource": { "resourceType": "Claim", "id": "1c852624-1d2d-2a0f-e14c-81d9030c328d", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2008-02-17T02:33:36-07:00", "end": "2008-02-17T02:48:36-07:00" }, "created": "2008-02-17T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:54990a97-8d24-a73a-b986-3fb38fa3542a" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:861ac2b8-9f89-c1d2-5fb2-f829d85f8dfc", "resource": { "resourceType": "Claim", "id": "861ac2b8-9f89-c1d2-5fb2-f829d85f8dfc", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2008-02-17T02:33:36-07:00", "end": "2008-02-17T02:48:36-07:00" }, "created": "2008-02-17T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:70ac2ecf-a620-69ad-2294-1cb568f28470", "resource": { "resourceType": "ExplanationOfBenefit", "id": "70ac2ecf-a620-69ad-2294-1cb568f28470", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "861ac2b8-9f89-c1d2-5fb2-f829d85f8dfc" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2008-02-17T02:48:36-07:00", "end": "2009-02-17T02:48:36-07:00" }, "created": "2008-02-17T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:861ac2b8-9f89-c1d2-5fb2-f829d85f8dfc" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2008-02-17T02:33:36-07:00", "end": "2008-02-17T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:24356772-97fa-129a-12d3-4e2c8d160b61" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b", "resource": { "resourceType": "Encounter", "id": "8fad8d79-2153-b7d5-14f0-6f406edc466b", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2009-02-22T02:33:36-07:00", "end": "2009-02-22T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2009-02-22T02:33:36-07:00", "end": "2009-02-22T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:e51c826d-9d31-1a0e-f7ac-d17d6cca1118", "resource": { "resourceType": "MedicationRequest", "id": "e51c826d-9d31-1a0e-f7ac-d17d6cca1118", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b" }, "authoredOn": "2009-02-22T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:3aae0b65-3ca7-d674-6f5d-f279f71626b0", "resource": { "resourceType": "Claim", "id": "3aae0b65-3ca7-d674-6f5d-f279f71626b0", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2009-02-22T02:33:36-07:00", "end": "2009-02-22T02:48:36-07:00" }, "created": "2009-02-22T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:e51c826d-9d31-1a0e-f7ac-d17d6cca1118" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:97f01aa6-0f28-d477-cf9a-7d5e41ab691e", "resource": { "resourceType": "MedicationRequest", "id": "97f01aa6-0f28-d477-cf9a-7d5e41ab691e", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b" }, "authoredOn": "2009-02-22T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:f051c6dc-748b-7226-cdb4-ff51d2b57ae5", "resource": { "resourceType": "Claim", "id": "f051c6dc-748b-7226-cdb4-ff51d2b57ae5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2009-02-22T02:33:36-07:00", "end": "2009-02-22T02:48:36-07:00" }, "created": "2009-02-22T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:97f01aa6-0f28-d477-cf9a-7d5e41ab691e" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:7fde242e-ee13-e9b1-4d59-b8bc5fb78a41", "resource": { "resourceType": "Claim", "id": "7fde242e-ee13-e9b1-4d59-b8bc5fb78a41", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2009-02-22T02:33:36-07:00", "end": "2009-02-22T02:48:36-07:00" }, "created": "2009-02-22T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e5a31a91-2e3c-0b28-a89b-cdb197a22a8c", "resource": { "resourceType": "ExplanationOfBenefit", "id": "e5a31a91-2e3c-0b28-a89b-cdb197a22a8c", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "7fde242e-ee13-e9b1-4d59-b8bc5fb78a41" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2009-02-22T02:48:36-07:00", "end": "2010-02-22T02:48:36-07:00" }, "created": "2009-02-22T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:7fde242e-ee13-e9b1-4d59-b8bc5fb78a41" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2009-02-22T02:33:36-07:00", "end": "2009-02-22T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:8fad8d79-2153-b7d5-14f0-6f406edc466b" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3", "resource": { "resourceType": "Encounter", "id": "f07ecd56-aba7-4e89-9dc0-89ac8322dfe3", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2010-02-28T02:33:36-07:00", "end": "2010-02-28T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2010-02-28T02:33:36-07:00", "end": "2010-02-28T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:0ba3680b-eab7-81f8-d6ce-aa7baaee4109", "resource": { "resourceType": "MedicationRequest", "id": "0ba3680b-eab7-81f8-d6ce-aa7baaee4109", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3" }, "authoredOn": "2010-02-28T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1cca6482-1cc7-9850-64d2-e67bf46fd38a", "resource": { "resourceType": "Claim", "id": "1cca6482-1cc7-9850-64d2-e67bf46fd38a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-02-28T02:33:36-07:00", "end": "2010-02-28T02:48:36-07:00" }, "created": "2010-02-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:0ba3680b-eab7-81f8-d6ce-aa7baaee4109" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:a40d9e29-6066-5bda-9a2a-22061e590623", "resource": { "resourceType": "MedicationRequest", "id": "a40d9e29-6066-5bda-9a2a-22061e590623", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3" }, "authoredOn": "2010-02-28T02:33:36-07:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:c5edc6a2-a343-095b-2f35-08269a3aed61", "resource": { "resourceType": "Claim", "id": "c5edc6a2-a343-095b-2f35-08269a3aed61", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-02-28T02:33:36-07:00", "end": "2010-02-28T02:48:36-07:00" }, "created": "2010-02-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:a40d9e29-6066-5bda-9a2a-22061e590623" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:30730f96-f11a-1753-42df-fa95b4eca687", "resource": { "resourceType": "Claim", "id": "30730f96-f11a-1753-42df-fa95b4eca687", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2010-02-28T02:33:36-07:00", "end": "2010-02-28T02:48:36-07:00" }, "created": "2010-02-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:2dce1dc4-6b10-ad84-7fa5-8ce23f3a84b4", "resource": { "resourceType": "ExplanationOfBenefit", "id": "2dce1dc4-6b10-ad84-7fa5-8ce23f3a84b4", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "30730f96-f11a-1753-42df-fa95b4eca687" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-02-28T02:48:36-07:00", "end": "2011-02-28T02:48:36-07:00" }, "created": "2010-02-28T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:30730f96-f11a-1753-42df-fa95b4eca687" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2010-02-28T02:33:36-07:00", "end": "2010-02-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:f07ecd56-aba7-4e89-9dc0-89ac8322dfe3" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "resource": { "resourceType": "Organization", "id": "23834663-ed53-3da9-b330-d6e1ecb8428e", "identifier": [ { "system": "https://github.com/synthetichealth/synthea", "value": "23834663-ed53-3da9-b330-d6e1ecb8428e" } ], "active": true, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/organization-type", "code": "prov", "display": "Healthcare Provider" } ], "text": "Healthcare Provider" } ], "name": "SOUTHCOAST HOSPITAL GROUP, INC", "telecom": [ { "system": "phone", "value": "5086793131" } ], "address": [ { "line": [ "363 HIGHLAND AVENUE" ], "city": "FALL RIVER", "state": "MA", "postalCode": "02720", "country": "US" } ] }, "request": { "method": "POST", "url": "Organization" } }, { "fullUrl": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "resource": { "resourceType": "Practitioner", "id": "c598151d-bd3f-3a84-8fa5-55d58f297f2f", "identifier": [ { "system": "http://hl7.org/fhir/sid/us-npi", "value": "9999999699" } ], "active": true, "name": [ { "family": "Kihn564", "given": [ "Isreal8" ], "prefix": [ "Dr." ] } ], "telecom": [ { "system": "email", "value": "Isreal8.Kihn564@example.com", "use": "work" } ], "address": [ { "line": [ "363 HIGHLAND AVENUE" ], "city": "FALL RIVER", "state": "MA", "postalCode": "02720", "country": "US" } ], "gender": "male" }, "request": { "method": "POST", "url": "Practitioner" } }, { "fullUrl": "urn:uuid:aeac9958-8cd1-90b0-d560-feeb41786c45", "resource": { "resourceType": "Encounter", "id": "aeac9958-8cd1-90b0-d560-feeb41786c45", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2010-05-02T03:33:36-06:00", "end": "2010-05-02T03:50:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2010-05-02T03:33:36-06:00", "end": "2010-05-02T03:50:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:35d5ef84-20a6-86a7-e3a9-6a9269540077", "resource": { "resourceType": "MedicationRequest", "id": "35d5ef84-20a6-86a7-e3a9-6a9269540077", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "1000126", "display": "1 ML medroxyprogesterone acetate 150 MG/ML Injection" } ], "text": "1 ML medroxyprogesterone acetate 150 MG/ML Injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:aeac9958-8cd1-90b0-d560-feeb41786c45" }, "authoredOn": "2010-05-02T03:33:36-06:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:bada1948-edf5-7680-66c5-98b467e98751", "resource": { "resourceType": "Claim", "id": "bada1948-edf5-7680-66c5-98b467e98751", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-05-02T03:33:36-06:00", "end": "2010-05-02T03:50:36-06:00" }, "created": "2010-05-02T03:50:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:35d5ef84-20a6-86a7-e3a9-6a9269540077" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:aeac9958-8cd1-90b0-d560-feeb41786c45" } ] } ], "total": { "value": 156.99, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:4be57b93-e638-c926-f5d3-b15318e8a7c0", "resource": { "resourceType": "Claim", "id": "4be57b93-e638-c926-f5d3-b15318e8a7c0", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2010-05-02T03:33:36-06:00", "end": "2010-05-02T03:50:36-06:00" }, "created": "2010-05-02T03:50:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:aeac9958-8cd1-90b0-d560-feeb41786c45" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:3c6a3490-3ffe-ce16-d2bf-3b1628c46603", "resource": { "resourceType": "ExplanationOfBenefit", "id": "3c6a3490-3ffe-ce16-d2bf-3b1628c46603", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "4be57b93-e638-c926-f5d3-b15318e8a7c0" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-05-02T03:50:36-06:00", "end": "2011-05-02T03:50:36-06:00" }, "created": "2010-05-02T03:50:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:4be57b93-e638-c926-f5d3-b15318e8a7c0" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "servicedPeriod": { "start": "2010-05-02T03:33:36-06:00", "end": "2010-05-02T03:50:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:aeac9958-8cd1-90b0-d560-feeb41786c45" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:68806a39-75f4-2866-d753-1df2c9bc0249", "resource": { "resourceType": "Encounter", "id": "68806a39-75f4-2866-d753-1df2c9bc0249", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:b8e46e2f-adb9-8808-055c-9d2984409d97", "resource": { "resourceType": "Procedure", "id": "b8e46e2f-adb9-8808-055c-9d2984409d97", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:68806a39-75f4-2866-d753-1df2c9bc0249" }, "performedPeriod": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:44:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:ea92cacd-4f85-3350-75af-7c741915c8ef", "resource": { "resourceType": "Procedure", "id": "ea92cacd-4f85-3350-75af-7c741915c8ef", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:68806a39-75f4-2866-d753-1df2c9bc0249" }, "performedPeriod": { "start": "2010-09-12T03:33:36-06:00", "end": "2010-09-12T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:446f8d7a-0895-24b3-522a-c47bf0c962ae", "resource": { "resourceType": "Claim", "id": "446f8d7a-0895-24b3-522a-c47bf0c962ae", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:48:36-06:00" }, "created": "2010-09-05T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:b8e46e2f-adb9-8808-055c-9d2984409d97" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:ea92cacd-4f85-3350-75af-7c741915c8ef" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:68806a39-75f4-2866-d753-1df2c9bc0249" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4336.19, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2624.67, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:8e67623d-877e-c0d0-e4e0-da8d87016635", "resource": { "resourceType": "ExplanationOfBenefit", "id": "8e67623d-877e-c0d0-e4e0-da8d87016635", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "446f8d7a-0895-24b3-522a-c47bf0c962ae" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-09-05T03:48:36-06:00", "end": "2011-09-05T03:48:36-06:00" }, "created": "2010-09-05T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:446f8d7a-0895-24b3-522a-c47bf0c962ae" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:68806a39-75f4-2866-d753-1df2c9bc0249" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4336.19, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 867.2379999999999, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3468.9519999999999, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4336.19, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4336.19, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2010-09-05T03:33:36-06:00", "end": "2010-09-05T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2624.67, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 524.9340000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2099.7360000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2624.67, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2624.67, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5568.688, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:4d4e5497-b6b5-68b4-397c-df8d56e491cc", "resource": { "resourceType": "Encounter", "id": "4d4e5497-b6b5-68b4-397c-df8d56e491cc", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:16a9498e-4f71-6c59-312a-8a29e2cd06c2", "resource": { "resourceType": "Procedure", "id": "16a9498e-4f71-6c59-312a-8a29e2cd06c2", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4d4e5497-b6b5-68b4-397c-df8d56e491cc" }, "performedPeriod": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:2ccc8704-59b5-2170-8be4-f051c2c247d8", "resource": { "resourceType": "Procedure", "id": "2ccc8704-59b5-2170-8be4-f051c2c247d8", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4d4e5497-b6b5-68b4-397c-df8d56e491cc" }, "performedPeriod": { "start": "2010-12-12T02:33:36-07:00", "end": "2010-12-12T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7f8adc50-95c6-2260-4f63-f3e8152a39de", "resource": { "resourceType": "Claim", "id": "7f8adc50-95c6-2260-4f63-f3e8152a39de", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" }, "created": "2010-12-05T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:16a9498e-4f71-6c59-312a-8a29e2cd06c2" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:2ccc8704-59b5-2170-8be4-f051c2c247d8" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:4d4e5497-b6b5-68b4-397c-df8d56e491cc" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2557.35, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3504.48, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:7d56400f-2c4c-f98d-1327-46b401f70a9e", "resource": { "resourceType": "ExplanationOfBenefit", "id": "7d56400f-2c4c-f98d-1327-46b401f70a9e", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "7f8adc50-95c6-2260-4f63-f3e8152a39de" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2010-12-05T02:48:36-07:00", "end": "2011-12-05T02:48:36-07:00" }, "created": "2010-12-05T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:7f8adc50-95c6-2260-4f63-f3e8152a39de" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:4d4e5497-b6b5-68b4-397c-df8d56e491cc" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2557.35, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 511.47, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2045.88, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2557.35, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2557.35, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2010-12-05T02:33:36-07:00", "end": "2010-12-05T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3504.48, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 700.8960000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2803.5840000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3504.48, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3504.48, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4849.464, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:bd6bf732-2cad-bcdd-3d99-399a249221f9", "resource": { "resourceType": "Encounter", "id": "bd6bf732-2cad-bcdd-3d99-399a249221f9", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:b2b3995a-e950-5d77-c732-cb0df2228150", "resource": { "resourceType": "Immunization", "id": "b2b3995a-e950-5d77-c732-cb0df2228150", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bd6bf732-2cad-bcdd-3d99-399a249221f9" }, "occurrenceDateTime": "2011-03-06T02:33:36-07:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:1999866d-bfb7-afcd-f92d-a8c682cf3525", "resource": { "resourceType": "Immunization", "id": "1999866d-bfb7-afcd-f92d-a8c682cf3525", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "52", "display": "Hep A, adult" } ], "text": "Hep A, adult" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bd6bf732-2cad-bcdd-3d99-399a249221f9" }, "occurrenceDateTime": "2011-03-06T02:33:36-07:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:56a2a161-2ab2-6fdc-1ce8-18b25b84bd01", "resource": { "resourceType": "Claim", "id": "56a2a161-2ab2-6fdc-1ce8-18b25b84bd01", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "created": "2011-03-06T02:48:36-07:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:b2b3995a-e950-5d77-c732-cb0df2228150" } }, { "sequence": 2, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:1999866d-bfb7-afcd-f92d-a8c682cf3525" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bd6bf732-2cad-bcdd-3d99-399a249221f9" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 3, "informationSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "52", "display": "Hep A, adult" } ], "text": "Hep A, adult" }, "net": { "value": 140.52, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:39006457-7fe1-c5b2-aae9-fd28ecce8d97", "resource": { "resourceType": "ExplanationOfBenefit", "id": "39006457-7fe1-c5b2-aae9-fd28ecce8d97", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "56a2a161-2ab2-6fdc-1ce8-18b25b84bd01" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-03-06T02:48:36-07:00", "end": "2012-03-06T02:48:36-07:00" }, "created": "2011-03-06T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:56a2a161-2ab2-6fdc-1ce8-18b25b84bd01" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:bd6bf732-2cad-bcdd-3d99-399a249221f9" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "informationSequence": [ 2 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "52", "display": "Hep A, adult" } ], "text": "Hep A, adult" }, "servicedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 224.83200000000003, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129", "resource": { "resourceType": "Encounter", "id": "9949a1ec-9385-0e30-2bb9-6863d0c41129", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:b9ed87d1-d632-ec11-4ca0-732f681aca2a", "resource": { "resourceType": "Observation", "id": "b9ed87d1-d632-ec11-4ca0-732f681aca2a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9a3bb69b-c423-e52a-3e6d-4add33657c24", "resource": { "resourceType": "Observation", "id": "9a3bb69b-c423-e52a-3e6d-4add33657c24", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 1, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1f3582d9-9d33-0ff3-1750-aa7c33a27edb", "resource": { "resourceType": "Observation", "id": "1f3582d9-9d33-0ff3-1750-aa7c33a27edb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 78.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ec09b365-0bfd-9545-e28e-33492ab99fb3", "resource": { "resourceType": "Observation", "id": "ec09b365-0bfd-9545-e28e-33492ab99fb3", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 27.97, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:705d50fb-59d2-0a65-3bf5-5865d3ac354e", "resource": { "resourceType": "Observation", "id": "705d50fb-59d2-0a65-3bf5-5865d3ac354e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 78, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 106, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:59995b0d-08ac-e740-b150-d1ca11404979", "resource": { "resourceType": "Observation", "id": "59995b0d-08ac-e740-b150-d1ca11404979", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 63, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8f9e75d6-ac8f-9cf8-c465-ca77bb19fd48", "resource": { "resourceType": "Observation", "id": "8f9e75d6-ac8f-9cf8-c465-ca77bb19fd48", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e1bce5b0-e654-109f-dbfb-3df29ac48b7e", "resource": { "resourceType": "Observation", "id": "e1bce5b0-e654-109f-dbfb-3df29ac48b7e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 114.9, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c7e06ba4-bbf6-7e41-fcf5-38f0765e8d33", "resource": { "resourceType": "Observation", "id": "c7e06ba4-bbf6-7e41-fcf5-38f0765e8d33", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 12.92, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:32c4d73f-c16c-0827-fd16-f14cbbb364b0", "resource": { "resourceType": "Observation", "id": "32c4d73f-c16c-0827-fd16-f14cbbb364b0", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 0.93, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:7e0161ac-a9bc-765a-72b9-e940a6c5f29d", "resource": { "resourceType": "Observation", "id": "7e0161ac-a9bc-765a-72b9-e940a6c5f29d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 9.86, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ad0625fe-be79-ea65-cef7-91d5286ef95d", "resource": { "resourceType": "Observation", "id": "ad0625fe-be79-ea65-cef7-91d5286ef95d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 142.91, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:42084acd-3c19-8b5f-65a6-20928ef3d2b9", "resource": { "resourceType": "Observation", "id": "42084acd-3c19-8b5f-65a6-20928ef3d2b9", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 4.17, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:188eb102-c85c-6e28-2f60-8c7c19a05bbb", "resource": { "resourceType": "Observation", "id": "188eb102-c85c-6e28-2f60-8c7c19a05bbb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 104.47, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b61a3bf6-c528-3df2-88dc-e63e6bb93adc", "resource": { "resourceType": "Observation", "id": "b61a3bf6-c528-3df2-88dc-e63e6bb93adc", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 25.92, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c78206b9-8a23-6903-4753-7fa5e0c9e461", "resource": { "resourceType": "Observation", "id": "c78206b9-8a23-6903-4753-7fa5e0c9e461", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 226.49, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e24d1aaf-fa60-d5b8-0eec-965356a40101", "resource": { "resourceType": "Observation", "id": "e24d1aaf-fa60-d5b8-0eec-965356a40101", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 182.23, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d3d87b63-25a3-63cc-c551-75ac3e9c1acb", "resource": { "resourceType": "Observation", "id": "d3d87b63-25a3-63cc-c551-75ac3e9c1acb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 133.28, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:95b19b92-de81-bdda-4ad9-4412f9e9b446", "resource": { "resourceType": "Observation", "id": "95b19b92-de81-bdda-4ad9-4412f9e9b446", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 56.77, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:847a8f91-5c37-3f20-d798-ef5a5acf2dd9", "resource": { "resourceType": "Observation", "id": "847a8f91-5c37-3f20-d798-ef5a5acf2dd9", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 2.78, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:662e90cc-1876-f185-a220-ec74ef901d6d", "resource": { "resourceType": "Observation", "id": "662e90cc-1876-f185-a220-ec74ef901d6d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 143.08, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:aaf2a6ac-5b61-e7dc-fb2a-be70b382fc50", "resource": { "resourceType": "Observation", "id": "aaf2a6ac-5b61-e7dc-fb2a-be70b382fc50", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ba07889e-1212-786a-2723-78a43ff54f5c", "resource": { "resourceType": "Observation", "id": "ba07889e-1212-786a-2723-78a43ff54f5c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "valueQuantity": { "value": 6.99, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f82f0d6f-2342-1ba5-c39f-b0265867ad58", "resource": { "resourceType": "Procedure", "id": "f82f0d6f-2342-1ba5-c39f-b0265867ad58", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "performedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:0728bbdd-01a7-f33e-f698-907f1619479d", "resource": { "resourceType": "Procedure", "id": "0728bbdd-01a7-f33e-f698-907f1619479d", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "performedPeriod": { "start": "2011-03-13T03:33:36-06:00", "end": "2011-03-13T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:dc0e506a-890a-3d62-7719-07a14c30d8fc", "resource": { "resourceType": "MedicationRequest", "id": "dc0e506a-890a-3d62-7719-07a14c30d8fc", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "authoredOn": "2011-03-06T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1d924c74-91dd-383b-5dfd-3d186a4b1ede", "resource": { "resourceType": "Claim", "id": "1d924c74-91dd-383b-5dfd-3d186a4b1ede", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "created": "2011-03-06T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:dc0e506a-890a-3d62-7719-07a14c30d8fc" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:80afe283-2bee-39bc-b8d5-c87ef51540ad", "resource": { "resourceType": "MedicationRequest", "id": "80afe283-2bee-39bc-b8d5-c87ef51540ad", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "authoredOn": "2011-03-06T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:e37cd3e1-3341-ff9e-e423-5b36161bc973", "resource": { "resourceType": "Claim", "id": "e37cd3e1-3341-ff9e-e423-5b36161bc973", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "created": "2011-03-06T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:80afe283-2bee-39bc-b8d5-c87ef51540ad" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d7c3136e-4f39-7ba5-8436-d1511b5d17bf", "resource": { "resourceType": "DiagnosticReport", "id": "d7c3136e-4f39-7ba5-8436-d1511b5d17bf", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "result": [ { "reference": "urn:uuid:e1bce5b0-e654-109f-dbfb-3df29ac48b7e", "display": "Glucose" }, { "reference": "urn:uuid:c7e06ba4-bbf6-7e41-fcf5-38f0765e8d33", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:32c4d73f-c16c-0827-fd16-f14cbbb364b0", "display": "Creatinine" }, { "reference": "urn:uuid:7e0161ac-a9bc-765a-72b9-e940a6c5f29d", "display": "Calcium" }, { "reference": "urn:uuid:ad0625fe-be79-ea65-cef7-91d5286ef95d", "display": "Sodium" }, { "reference": "urn:uuid:42084acd-3c19-8b5f-65a6-20928ef3d2b9", "display": "Potassium" }, { "reference": "urn:uuid:188eb102-c85c-6e28-2f60-8c7c19a05bbb", "display": "Chloride" }, { "reference": "urn:uuid:b61a3bf6-c528-3df2-88dc-e63e6bb93adc", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:631141b4-4380-a027-884c-ddd27eb867cf", "resource": { "resourceType": "DiagnosticReport", "id": "631141b4-4380-a027-884c-ddd27eb867cf", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" }, "effectiveDateTime": "2011-03-06T02:33:36-07:00", "issued": "2011-03-06T02:33:36.965-07:00", "result": [ { "reference": "urn:uuid:c78206b9-8a23-6903-4753-7fa5e0c9e461", "display": "Total Cholesterol" }, { "reference": "urn:uuid:e24d1aaf-fa60-d5b8-0eec-965356a40101", "display": "Triglycerides" }, { "reference": "urn:uuid:d3d87b63-25a3-63cc-c551-75ac3e9c1acb", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:95b19b92-de81-bdda-4ad9-4412f9e9b446", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:693bc61b-1340-dbeb-6ace-0a141e39db9c", "resource": { "resourceType": "Claim", "id": "693bc61b-1340-dbeb-6ace-0a141e39db9c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "created": "2011-03-06T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:f82f0d6f-2342-1ba5-c39f-b0265867ad58" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:0728bbdd-01a7-f33e-f698-907f1619479d" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3001.63, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2986.15, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ef7ce09c-c50e-270e-68a8-d7c19d151e2f", "resource": { "resourceType": "ExplanationOfBenefit", "id": "ef7ce09c-c50e-270e-68a8-d7c19d151e2f", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "693bc61b-1340-dbeb-6ace-0a141e39db9c" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-03-06T02:48:36-07:00", "end": "2012-03-06T02:48:36-07:00" }, "created": "2011-03-06T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:693bc61b-1340-dbeb-6ace-0a141e39db9c" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:9949a1ec-9385-0e30-2bb9-6863d0c41129" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3001.63, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 600.326, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2401.304, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3001.63, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3001.63, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-03-06T02:33:36-07:00", "end": "2011-03-06T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2986.15, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 597.23, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2388.92, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2986.15, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2986.15, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4790.224, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:52c2cad5-559a-bdcc-4af3-a439dbddbb46", "resource": { "resourceType": "Encounter", "id": "52c2cad5-559a-bdcc-4af3-a439dbddbb46", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-05-04T03:33:36-06:00", "end": "2011-05-04T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2011-05-04T03:33:36-06:00", "end": "2011-05-04T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:c2e88a79-3559-b16f-01a0-653dfe504483", "resource": { "resourceType": "MedicationRequest", "id": "c2e88a79-3559-b16f-01a0-653dfe504483", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "807283", "display": "Mirena 52 MG Intrauterine System" } ], "text": "Mirena 52 MG Intrauterine System" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:52c2cad5-559a-bdcc-4af3-a439dbddbb46" }, "authoredOn": "2011-05-04T03:33:36-06:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1e150ded-f92c-9962-6b92-58f2fb137c72", "resource": { "resourceType": "Claim", "id": "1e150ded-f92c-9962-6b92-58f2fb137c72", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-05-04T03:33:36-06:00", "end": "2011-05-04T03:48:36-06:00" }, "created": "2011-05-04T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:c2e88a79-3559-b16f-01a0-653dfe504483" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:52c2cad5-559a-bdcc-4af3-a439dbddbb46" } ] } ], "total": { "value": 1206.03, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:35b1bffb-8204-2ed2-3505-a2b2d02c94c9", "resource": { "resourceType": "Claim", "id": "35b1bffb-8204-2ed2-3505-a2b2d02c94c9", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-05-04T03:33:36-06:00", "end": "2011-05-04T03:48:36-06:00" }, "created": "2011-05-04T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:52c2cad5-559a-bdcc-4af3-a439dbddbb46" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f28a22c4-347c-7e92-9013-612271828cf1", "resource": { "resourceType": "ExplanationOfBenefit", "id": "f28a22c4-347c-7e92-9013-612271828cf1", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "35b1bffb-8204-2ed2-3505-a2b2d02c94c9" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-05-04T03:48:36-06:00", "end": "2012-05-04T03:48:36-06:00" }, "created": "2011-05-04T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:35b1bffb-8204-2ed2-3505-a2b2d02c94c9" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "servicedPeriod": { "start": "2011-05-04T03:33:36-06:00", "end": "2011-05-04T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:52c2cad5-559a-bdcc-4af3-a439dbddbb46" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:8355a5f0-2fef-d53e-9118-917efa5a74c4", "resource": { "resourceType": "Encounter", "id": "8355a5f0-2fef-d53e-9118-917efa5a74c4", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:974c2c2c-4e89-c9a3-9e57-543ba90e9798", "resource": { "resourceType": "Procedure", "id": "974c2c2c-4e89-c9a3-9e57-543ba90e9798", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:8355a5f0-2fef-d53e-9118-917efa5a74c4" }, "performedPeriod": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:3b78f3d6-7c96-095e-478f-66cecfded37c", "resource": { "resourceType": "Procedure", "id": "3b78f3d6-7c96-095e-478f-66cecfded37c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:8355a5f0-2fef-d53e-9118-917efa5a74c4" }, "performedPeriod": { "start": "2011-05-08T03:33:36-06:00", "end": "2011-05-08T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:fc86d6f1-2adc-cbc2-a8c3-e6c9bed8a0c1", "resource": { "resourceType": "Claim", "id": "fc86d6f1-2adc-cbc2-a8c3-e6c9bed8a0c1", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" }, "created": "2011-05-07T04:39:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:974c2c2c-4e89-c9a3-9e57-543ba90e9798" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:3b78f3d6-7c96-095e-478f-66cecfded37c" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:8355a5f0-2fef-d53e-9118-917efa5a74c4" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "net": { "value": 11159.26, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "net": { "value": 17207.7, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:5afc165d-f099-0efe-3031-b2290db98dbb", "resource": { "resourceType": "ExplanationOfBenefit", "id": "5afc165d-f099-0efe-3031-b2290db98dbb", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "fc86d6f1-2adc-cbc2-a8c3-e6c9bed8a0c1" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-05-07T04:39:36-06:00", "end": "2012-05-07T04:39:36-06:00" }, "created": "2011-05-07T04:39:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:fc86d6f1-2adc-cbc2-a8c3-e6c9bed8a0c1" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:8355a5f0-2fef-d53e-9118-917efa5a74c4" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "servicedPeriod": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 11159.26, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 2231.8520000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 8927.408000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 11159.26, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 11159.26, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "servicedPeriod": { "start": "2011-05-07T03:33:36-06:00", "end": "2011-05-07T04:39:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 17207.7, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 3441.5400000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 13766.160000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 17207.7, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 17207.7, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 22693.568000000003, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:cc8b244c-ebb3-037f-cbda-f8e9f19732c8", "resource": { "resourceType": "Encounter", "id": "cc8b244c-ebb3-037f-cbda-f8e9f19732c8", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:858121ef-c3ab-4993-8c41-d3e30d43e291", "resource": { "resourceType": "Procedure", "id": "858121ef-c3ab-4993-8c41-d3e30d43e291", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:cc8b244c-ebb3-037f-cbda-f8e9f19732c8" }, "performedPeriod": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:20b20470-fb49-e54e-2934-f4ce8d179a90", "resource": { "resourceType": "Procedure", "id": "20b20470-fb49-e54e-2934-f4ce8d179a90", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:cc8b244c-ebb3-037f-cbda-f8e9f19732c8" }, "performedPeriod": { "start": "2011-06-12T03:33:36-06:00", "end": "2011-06-12T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:2dcd9526-30ee-0cb1-582e-c3a94338f7d1", "resource": { "resourceType": "Claim", "id": "2dcd9526-30ee-0cb1-582e-c3a94338f7d1", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" }, "created": "2011-06-05T03:52:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:858121ef-c3ab-4993-8c41-d3e30d43e291" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:20b20470-fb49-e54e-2934-f4ce8d179a90" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:cc8b244c-ebb3-037f-cbda-f8e9f19732c8" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4981.88, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3699.84, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6507c103-2b8a-3407-eaf8-7d3cc8fa33fc", "resource": { "resourceType": "ExplanationOfBenefit", "id": "6507c103-2b8a-3407-eaf8-7d3cc8fa33fc", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "2dcd9526-30ee-0cb1-582e-c3a94338f7d1" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-06-05T03:52:36-06:00", "end": "2012-06-05T03:52:36-06:00" }, "created": "2011-06-05T03:52:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:2dcd9526-30ee-0cb1-582e-c3a94338f7d1" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:cc8b244c-ebb3-037f-cbda-f8e9f19732c8" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4981.88, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 996.3760000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3985.5040000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4981.88, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4981.88, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-06-05T03:33:36-06:00", "end": "2011-06-05T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3699.84, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 739.9680000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2959.8720000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3699.84, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3699.84, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6945.376, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:1eb1eb4e-dd29-fc92-6e48-26fa909a6e92", "resource": { "resourceType": "Encounter", "id": "1eb1eb4e-dd29-fc92-6e48-26fa909a6e92", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:0d0a379a-8195-e967-c429-6c0d00fbc675", "resource": { "resourceType": "Procedure", "id": "0d0a379a-8195-e967-c429-6c0d00fbc675", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:1eb1eb4e-dd29-fc92-6e48-26fa909a6e92" }, "performedPeriod": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:47:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:a160feee-7a82-fe96-9a6e-b7ab9ee307ae", "resource": { "resourceType": "Procedure", "id": "a160feee-7a82-fe96-9a6e-b7ab9ee307ae", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:1eb1eb4e-dd29-fc92-6e48-26fa909a6e92" }, "performedPeriod": { "start": "2011-09-11T03:33:36-06:00", "end": "2011-09-11T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:fb03e444-b0fa-ae8d-d369-20af655df16a", "resource": { "resourceType": "Claim", "id": "fb03e444-b0fa-ae8d-d369-20af655df16a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:48:36-06:00" }, "created": "2011-09-04T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:0d0a379a-8195-e967-c429-6c0d00fbc675" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:a160feee-7a82-fe96-9a6e-b7ab9ee307ae" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:1eb1eb4e-dd29-fc92-6e48-26fa909a6e92" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3952.97, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4734.1, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:71613c39-e789-b9bd-03fa-fa647d395846", "resource": { "resourceType": "ExplanationOfBenefit", "id": "71613c39-e789-b9bd-03fa-fa647d395846", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "fb03e444-b0fa-ae8d-d369-20af655df16a" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-09-04T03:48:36-06:00", "end": "2012-09-04T03:48:36-06:00" }, "created": "2011-09-04T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:fb03e444-b0fa-ae8d-d369-20af655df16a" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:1eb1eb4e-dd29-fc92-6e48-26fa909a6e92" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3952.97, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 790.594, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3162.376, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3952.97, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3952.97, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-09-04T03:33:36-06:00", "end": "2011-09-04T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4734.1, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 946.8200000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3787.2800000000008, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4734.1, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4734.1, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6949.656000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:62cdbc02-408a-e47d-2702-1ea2c240a8cc", "resource": { "resourceType": "Encounter", "id": "62cdbc02-408a-e47d-2702-1ea2c240a8cc", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:c981a39c-21cc-a72f-0054-451ef8948e3c", "resource": { "resourceType": "Procedure", "id": "c981a39c-21cc-a72f-0054-451ef8948e3c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:62cdbc02-408a-e47d-2702-1ea2c240a8cc" }, "performedPeriod": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:8001d745-d11f-3ca0-6258-fbff44fec18e", "resource": { "resourceType": "Procedure", "id": "8001d745-d11f-3ca0-6258-fbff44fec18e", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:62cdbc02-408a-e47d-2702-1ea2c240a8cc" }, "performedPeriod": { "start": "2011-12-11T02:33:36-07:00", "end": "2011-12-11T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:187c9c32-864a-b2b4-75f2-15abb50544b7", "resource": { "resourceType": "Claim", "id": "187c9c32-864a-b2b4-75f2-15abb50544b7", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" }, "created": "2011-12-04T02:49:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:c981a39c-21cc-a72f-0054-451ef8948e3c" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:8001d745-d11f-3ca0-6258-fbff44fec18e" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:62cdbc02-408a-e47d-2702-1ea2c240a8cc" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4634.04, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2956.0, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:aee8ec7b-04c2-e142-2e1c-9fec36df8e2b", "resource": { "resourceType": "ExplanationOfBenefit", "id": "aee8ec7b-04c2-e142-2e1c-9fec36df8e2b", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "187c9c32-864a-b2b4-75f2-15abb50544b7" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2011-12-04T02:49:36-07:00", "end": "2012-12-04T02:49:36-07:00" }, "created": "2011-12-04T02:49:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:187c9c32-864a-b2b4-75f2-15abb50544b7" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:62cdbc02-408a-e47d-2702-1ea2c240a8cc" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4634.04, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 926.808, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3707.232, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4634.04, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4634.04, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2011-12-04T02:33:36-07:00", "end": "2011-12-04T02:49:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2956.0, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 591.2, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2364.8, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2956.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2956.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6072.032, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:57329653-0469-6b3d-74c1-b82fe29468a3", "resource": { "resourceType": "Encounter", "id": "57329653-0469-6b3d-74c1-b82fe29468a3", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:56ac9a7d-130c-2e13-2dcf-d1297caf8b1f", "resource": { "resourceType": "Procedure", "id": "56ac9a7d-130c-2e13-2dcf-d1297caf8b1f", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:57329653-0469-6b3d-74c1-b82fe29468a3" }, "performedPeriod": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:47:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:8da67e01-1a50-c359-8e2a-3d9f846a2d2e", "resource": { "resourceType": "Procedure", "id": "8da67e01-1a50-c359-8e2a-3d9f846a2d2e", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:57329653-0469-6b3d-74c1-b82fe29468a3" }, "performedPeriod": { "start": "2012-03-11T03:33:36-06:00", "end": "2012-03-11T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:9a98831d-2da3-f8a7-2e86-14874b121b6d", "resource": { "resourceType": "Claim", "id": "9a98831d-2da3-f8a7-2e86-14874b121b6d", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:48:36-07:00" }, "created": "2012-03-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:56ac9a7d-130c-2e13-2dcf-d1297caf8b1f" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:8da67e01-1a50-c359-8e2a-3d9f846a2d2e" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:57329653-0469-6b3d-74c1-b82fe29468a3" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4292.08, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3876.01, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:cf25fd78-abce-61c0-c428-c249a52f104c", "resource": { "resourceType": "ExplanationOfBenefit", "id": "cf25fd78-abce-61c0-c428-c249a52f104c", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "9a98831d-2da3-f8a7-2e86-14874b121b6d" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-03-04T02:48:36-07:00", "end": "2013-03-04T02:48:36-07:00" }, "created": "2012-03-04T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:9a98831d-2da3-f8a7-2e86-14874b121b6d" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:57329653-0469-6b3d-74c1-b82fe29468a3" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4292.08, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 858.416, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3433.664, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4292.08, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4292.08, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-03-04T02:33:36-07:00", "end": "2012-03-04T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3876.01, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 775.2020000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3100.8080000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3876.01, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3876.01, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6534.472000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518", "resource": { "resourceType": "Encounter", "id": "f774359e-763d-68f6-23ed-db69e79e5518", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d9478fa9-0722-81cc-9c3f-044d7fd8ef34", "resource": { "resourceType": "Condition", "id": "d9478fa9-0722-81cc-9c3f-044d7fd8ef34", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "368581000119106", "display": "Neuropathy due to type 2 diabetes mellitus (disorder)" } ], "text": "Neuropathy due to type 2 diabetes mellitus (disorder)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "onsetDateTime": "2012-03-18T03:33:36-06:00", "recordedDate": "2012-03-18T03:33:36-06:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:c93fe93b-6d80-61dc-5202-024f7f18ddaa", "resource": { "resourceType": "Observation", "id": "c93fe93b-6d80-61dc-5202-024f7f18ddaa", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8ca862b2-b558-63fb-002e-4a1b98562ae2", "resource": { "resourceType": "Observation", "id": "8ca862b2-b558-63fb-002e-4a1b98562ae2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 2, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:34de079f-70a8-799a-b2fc-9f40115cd6b0", "resource": { "resourceType": "Observation", "id": "34de079f-70a8-799a-b2fc-9f40115cd6b0", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 80.4, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a9940a6f-060c-4e6f-1bb8-98fefbc8dc93", "resource": { "resourceType": "Observation", "id": "a9940a6f-060c-4e6f-1bb8-98fefbc8dc93", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 28.6, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1873876b-11da-8253-4265-206133c5da3b", "resource": { "resourceType": "Observation", "id": "1873876b-11da-8253-4265-206133c5da3b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 85, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 129, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:960002e5-a0c1-1d6d-53e2-3b9164441a4b", "resource": { "resourceType": "Observation", "id": "960002e5-a0c1-1d6d-53e2-3b9164441a4b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 92, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:748916b2-d572-a290-5753-ba66f32d0760", "resource": { "resourceType": "Observation", "id": "748916b2-d572-a290-5753-ba66f32d0760", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 14, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:758502d7-c827-63e2-c96d-9842c83d4b52", "resource": { "resourceType": "Observation", "id": "758502d7-c827-63e2-c96d-9842c83d4b52", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 113.62, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:37371581-24cc-fdbd-a144-271c6ecb1eb9", "resource": { "resourceType": "Observation", "id": "37371581-24cc-fdbd-a144-271c6ecb1eb9", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 11.07, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:87401e37-65f8-1bd9-958b-57d7f2238cb2", "resource": { "resourceType": "Observation", "id": "87401e37-65f8-1bd9-958b-57d7f2238cb2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 0.94, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:71e66051-154a-ecaa-ac11-b3dcdd91aee3", "resource": { "resourceType": "Observation", "id": "71e66051-154a-ecaa-ac11-b3dcdd91aee3", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 10.18, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:90c5b8aa-6844-e706-14f8-dbe718cf25bb", "resource": { "resourceType": "Observation", "id": "90c5b8aa-6844-e706-14f8-dbe718cf25bb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 137.03, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c96fea93-f896-c60a-08f6-a01b8fcd50fe", "resource": { "resourceType": "Observation", "id": "c96fea93-f896-c60a-08f6-a01b8fcd50fe", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 4.19, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1890480b-735f-df3e-2307-055d15bb0c80", "resource": { "resourceType": "Observation", "id": "1890480b-735f-df3e-2307-055d15bb0c80", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 101.71, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5fa5292c-8968-36f7-5ba8-cbde2722f530", "resource": { "resourceType": "Observation", "id": "5fa5292c-8968-36f7-5ba8-cbde2722f530", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 20.3, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5594e6e9-6dbc-f6fc-1b43-4af7c23a7a58", "resource": { "resourceType": "Observation", "id": "5594e6e9-6dbc-f6fc-1b43-4af7c23a7a58", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 232.67, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8c8b4cf5-ee4b-2b6c-93ed-b63caf3a3f22", "resource": { "resourceType": "Observation", "id": "8c8b4cf5-ee4b-2b6c-93ed-b63caf3a3f22", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 187.93, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:04e7b706-f56e-e9de-d5bd-1fcc391c905d", "resource": { "resourceType": "Observation", "id": "04e7b706-f56e-e9de-d5bd-1fcc391c905d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 138.37, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:7cd34d3b-ba2b-46ca-8d3f-cbe779a6f281", "resource": { "resourceType": "Observation", "id": "7cd34d3b-ba2b-46ca-8d3f-cbe779a6f281", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 56.72, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c99a13db-6121-bd26-9721-a9c236700bf0", "resource": { "resourceType": "Observation", "id": "c99a13db-6121-bd26-9721-a9c236700bf0", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 2.07, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3258c23e-88a5-ec54-275f-059c9fe36f7e", "resource": { "resourceType": "Observation", "id": "3258c23e-88a5-ec54-275f-059c9fe36f7e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6690-2", "display": "Leukocytes [#/volume] in Blood by Automated count" } ], "text": "Leukocytes [#/volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 7.9609, "unit": "10*3/uL", "system": "http://unitsofmeasure.org", "code": "10*3/uL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:563c950f-88b4-d03b-1b27-c81393590b33", "resource": { "resourceType": "Observation", "id": "563c950f-88b4-d03b-1b27-c81393590b33", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "789-8", "display": "Erythrocytes [#/volume] in Blood by Automated count" } ], "text": "Erythrocytes [#/volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 4.5615, "unit": "10*6/uL", "system": "http://unitsofmeasure.org", "code": "10*6/uL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:72b18fb3-d264-d7b2-abe6-d6b4d66e3f4f", "resource": { "resourceType": "Observation", "id": "72b18fb3-d264-d7b2-abe6-d6b4d66e3f4f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "718-7", "display": "Hemoglobin [Mass/volume] in Blood" } ], "text": "Hemoglobin [Mass/volume] in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 15.9, "unit": "g/dL", "system": "http://unitsofmeasure.org", "code": "g/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:62aee104-33d6-7d25-7506-69d2e82ae18d", "resource": { "resourceType": "Observation", "id": "62aee104-33d6-7d25-7506-69d2e82ae18d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4544-3", "display": "Hematocrit [Volume Fraction] of Blood by Automated count" } ], "text": "Hematocrit [Volume Fraction] of Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 35.312, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e7185f42-1c03-4572-fe43-6b98cc5cb0ac", "resource": { "resourceType": "Observation", "id": "e7185f42-1c03-4572-fe43-6b98cc5cb0ac", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "787-2", "display": "MCV [Entitic volume] by Automated count" } ], "text": "MCV [Entitic volume] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 82.793, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5c274f4a-b743-4914-7eef-3460b337fc2a", "resource": { "resourceType": "Observation", "id": "5c274f4a-b743-4914-7eef-3460b337fc2a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "785-6", "display": "MCH [Entitic mass] by Automated count" } ], "text": "MCH [Entitic mass] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 31.055, "unit": "pg", "system": "http://unitsofmeasure.org", "code": "pg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:103beb07-b03f-ab82-a4a0-3845aaf48452", "resource": { "resourceType": "Observation", "id": "103beb07-b03f-ab82-a4a0-3845aaf48452", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "786-4", "display": "MCHC [Mass/volume] by Automated count" } ], "text": "MCHC [Mass/volume] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 33.295, "unit": "g/dL", "system": "http://unitsofmeasure.org", "code": "g/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d09c5b29-fb8a-a4d9-f6c7-79f6ff09d679", "resource": { "resourceType": "Observation", "id": "d09c5b29-fb8a-a4d9-f6c7-79f6ff09d679", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "21000-5", "display": "Erythrocyte distribution width [Entitic volume] by Automated count" } ], "text": "Erythrocyte distribution width [Entitic volume] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 44.746, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b7bd1815-ac7c-01b8-31a9-d6ce691ea983", "resource": { "resourceType": "Observation", "id": "b7bd1815-ac7c-01b8-31a9-d6ce691ea983", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "777-3", "display": "Platelets [#/volume] in Blood by Automated count" } ], "text": "Platelets [#/volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 410.79, "unit": "10*3/uL", "system": "http://unitsofmeasure.org", "code": "10*3/uL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d1f9e61b-e27b-3d6a-3399-802066f2feac", "resource": { "resourceType": "Observation", "id": "d1f9e61b-e27b-3d6a-3399-802066f2feac", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "32207-3", "display": "Platelet distribution width [Entitic volume] in Blood by Automated count" } ], "text": "Platelet distribution width [Entitic volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 160.56, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3865e0ef-44ce-9a4a-f83d-35d58ec50a85", "resource": { "resourceType": "Observation", "id": "3865e0ef-44ce-9a4a-f83d-35d58ec50a85", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "32623-1", "display": "Platelet mean volume [Entitic volume] in Blood by Automated count" } ], "text": "Platelet mean volume [Entitic volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 10.194, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f0cc4a50-c298-dc63-9478-163b852d2a3b", "resource": { "resourceType": "Observation", "id": "f0cc4a50-c298-dc63-9478-163b852d2a3b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 160.83, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4d63100c-cb25-8a56-3b5e-1717b46d691f", "resource": { "resourceType": "Observation", "id": "4d63100c-cb25-8a56-3b5e-1717b46d691f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f94b3d2a-7a3d-d880-66ce-7bfe49f55a61", "resource": { "resourceType": "Observation", "id": "f94b3d2a-7a3d-d880-66ce-7bfe49f55a61", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "valueQuantity": { "value": 7.15, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:180aca5d-333e-a25b-3e0e-dde283a34b1f", "resource": { "resourceType": "Procedure", "id": "180aca5d-333e-a25b-3e0e-dde283a34b1f", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "performedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:50ee81bf-6e4a-1625-0756-97ef7758109e", "resource": { "resourceType": "MedicationRequest", "id": "50ee81bf-6e4a-1625-0756-97ef7758109e", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "authoredOn": "2012-03-18T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b2f9e9be-8375-f6be-afe3-ad963d02f6d6", "resource": { "resourceType": "Claim", "id": "b2f9e9be-8375-f6be-afe3-ad963d02f6d6", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "created": "2012-03-18T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:50ee81bf-6e4a-1625-0756-97ef7758109e" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:adf66b58-a281-97d6-6e2f-7de8819f9333", "resource": { "resourceType": "MedicationRequest", "id": "adf66b58-a281-97d6-6e2f-7de8819f9333", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "authoredOn": "2012-03-18T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:f8922786-e0ac-f847-f46a-d827d0f77f99", "resource": { "resourceType": "Claim", "id": "f8922786-e0ac-f847-f46a-d827d0f77f99", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "created": "2012-03-18T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:adf66b58-a281-97d6-6e2f-7de8819f9333" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e5922ff7-fbfc-9ebe-2bce-459c609641a9", "resource": { "resourceType": "Immunization", "id": "e5922ff7-fbfc-9ebe-2bce-459c609641a9", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "occurrenceDateTime": "2012-03-18T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:1a2316fe-a9cc-1ca1-acc4-9ca3687de242", "resource": { "resourceType": "Immunization", "id": "1a2316fe-a9cc-1ca1-acc4-9ca3687de242", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "113", "display": "Td (adult) preservative free" } ], "text": "Td (adult) preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "occurrenceDateTime": "2012-03-18T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:b88e0acc-a84b-5b2c-19c3-310c720ef94a", "resource": { "resourceType": "Immunization", "id": "b88e0acc-a84b-5b2c-19c3-310c720ef94a", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "52", "display": "Hep A, adult" } ], "text": "Hep A, adult" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "occurrenceDateTime": "2012-03-18T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:4447efe3-65a1-16dd-bc04-35a3d37f31ae", "resource": { "resourceType": "DiagnosticReport", "id": "4447efe3-65a1-16dd-bc04-35a3d37f31ae", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:758502d7-c827-63e2-c96d-9842c83d4b52", "display": "Glucose" }, { "reference": "urn:uuid:37371581-24cc-fdbd-a144-271c6ecb1eb9", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:87401e37-65f8-1bd9-958b-57d7f2238cb2", "display": "Creatinine" }, { "reference": "urn:uuid:71e66051-154a-ecaa-ac11-b3dcdd91aee3", "display": "Calcium" }, { "reference": "urn:uuid:90c5b8aa-6844-e706-14f8-dbe718cf25bb", "display": "Sodium" }, { "reference": "urn:uuid:c96fea93-f896-c60a-08f6-a01b8fcd50fe", "display": "Potassium" }, { "reference": "urn:uuid:1890480b-735f-df3e-2307-055d15bb0c80", "display": "Chloride" }, { "reference": "urn:uuid:5fa5292c-8968-36f7-5ba8-cbde2722f530", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:d9b32ec0-962f-2d12-a78d-23116a6589a6", "resource": { "resourceType": "DiagnosticReport", "id": "d9b32ec0-962f-2d12-a78d-23116a6589a6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:5594e6e9-6dbc-f6fc-1b43-4af7c23a7a58", "display": "Total Cholesterol" }, { "reference": "urn:uuid:8c8b4cf5-ee4b-2b6c-93ed-b63caf3a3f22", "display": "Triglycerides" }, { "reference": "urn:uuid:04e7b706-f56e-e9de-d5bd-1fcc391c905d", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:7cd34d3b-ba2b-46ca-8d3f-cbe779a6f281", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:d44428e3-1c1b-9fef-b834-37dcb293d33d", "resource": { "resourceType": "DiagnosticReport", "id": "d44428e3-1c1b-9fef-b834-37dcb293d33d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "58410-2", "display": "Complete blood count (hemogram) panel - Blood by Automated count" } ], "text": "Complete blood count (hemogram) panel - Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" }, "effectiveDateTime": "2012-03-18T03:33:36-06:00", "issued": "2012-03-18T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:3258c23e-88a5-ec54-275f-059c9fe36f7e", "display": "Leukocytes [#/volume] in Blood by Automated count" }, { "reference": "urn:uuid:563c950f-88b4-d03b-1b27-c81393590b33", "display": "Erythrocytes [#/volume] in Blood by Automated count" }, { "reference": "urn:uuid:72b18fb3-d264-d7b2-abe6-d6b4d66e3f4f", "display": "Hemoglobin [Mass/volume] in Blood" }, { "reference": "urn:uuid:62aee104-33d6-7d25-7506-69d2e82ae18d", "display": "Hematocrit [Volume Fraction] of Blood by Automated count" }, { "reference": "urn:uuid:e7185f42-1c03-4572-fe43-6b98cc5cb0ac", "display": "MCV [Entitic volume] by Automated count" }, { "reference": "urn:uuid:5c274f4a-b743-4914-7eef-3460b337fc2a", "display": "MCH [Entitic mass] by Automated count" }, { "reference": "urn:uuid:103beb07-b03f-ab82-a4a0-3845aaf48452", "display": "MCHC [Mass/volume] by Automated count" }, { "reference": "urn:uuid:d09c5b29-fb8a-a4d9-f6c7-79f6ff09d679", "display": "Erythrocyte distribution width [Entitic volume] by Automated count" }, { "reference": "urn:uuid:b7bd1815-ac7c-01b8-31a9-d6ce691ea983", "display": "Platelets [#/volume] in Blood by Automated count" }, { "reference": "urn:uuid:d1f9e61b-e27b-3d6a-3399-802066f2feac", "display": "Platelet distribution width [Entitic volume] in Blood by Automated count" }, { "reference": "urn:uuid:3865e0ef-44ce-9a4a-f83d-35d58ec50a85", "display": "Platelet mean volume [Entitic volume] in Blood by Automated count" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:e44388ec-e70b-7485-b8f5-65d573e93910", "resource": { "resourceType": "Claim", "id": "e44388ec-e70b-7485-b8f5-65d573e93910", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "created": "2012-03-18T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:e5922ff7-fbfc-9ebe-2bce-459c609641a9" } }, { "sequence": 2, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:1a2316fe-a9cc-1ca1-acc4-9ca3687de242" } }, { "sequence": 3, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:b88e0acc-a84b-5b2c-19c3-310c720ef94a" } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:d9478fa9-0722-81cc-9c3f-044d7fd8ef34" } } ], "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:180aca5d-333e-a25b-3e0e-dde283a34b1f" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 3, "informationSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "113", "display": "Td (adult) preservative free" } ], "text": "Td (adult) preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 4, "informationSequence": [ 3 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "52", "display": "Hep A, adult" } ], "text": "Hep A, adult" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 5, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "net": { "value": 518.29, "currency": "USD" } }, { "sequence": 6, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "368581000119106", "display": "Neuropathy due to type 2 diabetes mellitus (disorder)" } ], "text": "Neuropathy due to type 2 diabetes mellitus (disorder)" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9168e224-122a-cf30-5b18-40945a41cb55", "resource": { "resourceType": "ExplanationOfBenefit", "id": "9168e224-122a-cf30-5b18-40945a41cb55", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "e44388ec-e70b-7485-b8f5-65d573e93910" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-03-18T03:48:36-06:00", "end": "2013-03-18T03:48:36-06:00" }, "created": "2012-03-18T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:e44388ec-e70b-7485-b8f5-65d573e93910" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:d9478fa9-0722-81cc-9c3f-044d7fd8ef34" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:f774359e-763d-68f6-23ed-db69e79e5518" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "informationSequence": [ 2 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "113", "display": "Td (adult) preservative free" } ], "text": "Td (adult) preservative free" }, "servicedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 4, "informationSequence": [ 3 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "52", "display": "Hep A, adult" } ], "text": "Hep A, adult" }, "servicedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 5, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "servicedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 518.29, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 103.658, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 414.632, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 518.29, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 518.29, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 6, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "368581000119106", "display": "Neuropathy due to type 2 diabetes mellitus (disorder)" } ], "text": "Neuropathy due to type 2 diabetes mellitus (disorder)" }, "servicedPeriod": { "start": "2012-03-18T03:33:36-06:00", "end": "2012-03-18T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 751.8800000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:9c3b5320-426f-f240-80ad-c15a0a63591f", "resource": { "resourceType": "Encounter", "id": "9c3b5320-426f-f240-80ad-c15a0a63591f", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:f4cd1fbe-c5bd-02da-0f05-f4215e0819df", "resource": { "resourceType": "Procedure", "id": "f4cd1fbe-c5bd-02da-0f05-f4215e0819df", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9c3b5320-426f-f240-80ad-c15a0a63591f" }, "performedPeriod": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:9d42765c-ff5e-b820-9f2a-e1f1d42beb2e", "resource": { "resourceType": "Procedure", "id": "9d42765c-ff5e-b820-9f2a-e1f1d42beb2e", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9c3b5320-426f-f240-80ad-c15a0a63591f" }, "performedPeriod": { "start": "2012-06-10T03:33:36-06:00", "end": "2012-06-10T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:c8e2d441-75a4-588f-256f-4c7469c926c8", "resource": { "resourceType": "Claim", "id": "c8e2d441-75a4-588f-256f-4c7469c926c8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" }, "created": "2012-06-03T03:51:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:f4cd1fbe-c5bd-02da-0f05-f4215e0819df" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:9d42765c-ff5e-b820-9f2a-e1f1d42beb2e" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:9c3b5320-426f-f240-80ad-c15a0a63591f" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2660.53, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 5004.96, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9077bd59-292f-a9a9-12f5-0ec4b67e54db", "resource": { "resourceType": "ExplanationOfBenefit", "id": "9077bd59-292f-a9a9-12f5-0ec4b67e54db", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "c8e2d441-75a4-588f-256f-4c7469c926c8" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-06-03T03:51:36-06:00", "end": "2013-06-03T03:51:36-06:00" }, "created": "2012-06-03T03:51:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:c8e2d441-75a4-588f-256f-4c7469c926c8" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:9c3b5320-426f-f240-80ad-c15a0a63591f" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2660.53, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 532.1060000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2128.4240000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2660.53, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2660.53, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-06-03T03:33:36-06:00", "end": "2012-06-03T03:51:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 5004.96, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 1000.9920000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 4003.9680000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 5004.96, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 5004.96, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6132.392000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:51b2bb2a-7761-b5d3-9df8-378b90663e82", "resource": { "resourceType": "Encounter", "id": "51b2bb2a-7761-b5d3-9df8-378b90663e82", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:1c7fd700-8033-8c7f-34e9-304da700248b", "resource": { "resourceType": "Procedure", "id": "1c7fd700-8033-8c7f-34e9-304da700248b", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:51b2bb2a-7761-b5d3-9df8-378b90663e82" }, "performedPeriod": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:bdc9036e-1b18-608d-a631-86017e9e1e80", "resource": { "resourceType": "Procedure", "id": "bdc9036e-1b18-608d-a631-86017e9e1e80", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:51b2bb2a-7761-b5d3-9df8-378b90663e82" }, "performedPeriod": { "start": "2012-09-09T03:33:36-06:00", "end": "2012-09-09T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:068228f1-b878-a8ee-1024-26de48abe5e5", "resource": { "resourceType": "Claim", "id": "068228f1-b878-a8ee-1024-26de48abe5e5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" }, "created": "2012-09-02T03:52:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:1c7fd700-8033-8c7f-34e9-304da700248b" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:bdc9036e-1b18-608d-a631-86017e9e1e80" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:51b2bb2a-7761-b5d3-9df8-378b90663e82" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 1889.09, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3094.21, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d71cc9f6-e42c-278a-2353-297b118091bd", "resource": { "resourceType": "ExplanationOfBenefit", "id": "d71cc9f6-e42c-278a-2353-297b118091bd", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "068228f1-b878-a8ee-1024-26de48abe5e5" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-09-02T03:52:36-06:00", "end": "2013-09-02T03:52:36-06:00" }, "created": "2012-09-02T03:52:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:068228f1-b878-a8ee-1024-26de48abe5e5" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:51b2bb2a-7761-b5d3-9df8-378b90663e82" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 1889.09, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 377.818, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1511.272, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 1889.09, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 1889.09, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-09-02T03:33:36-06:00", "end": "2012-09-02T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3094.21, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 618.8420000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2475.3680000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3094.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3094.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3986.6400000000005, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:65fd7200-6352-fa64-e292-711836920653", "resource": { "resourceType": "Encounter", "id": "65fd7200-6352-fa64-e292-711836920653", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:ca7c6420-6b4c-1afa-a88f-c337a8091d36", "resource": { "resourceType": "Procedure", "id": "ca7c6420-6b4c-1afa-a88f-c337a8091d36", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:65fd7200-6352-fa64-e292-711836920653" }, "performedPeriod": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:47:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:609e3cb0-2289-eff1-785e-2272fb21c984", "resource": { "resourceType": "Procedure", "id": "609e3cb0-2289-eff1-785e-2272fb21c984", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:65fd7200-6352-fa64-e292-711836920653" }, "performedPeriod": { "start": "2012-12-09T02:33:36-07:00", "end": "2012-12-09T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:63487a3b-54eb-d4f1-35db-828a27b2bc6b", "resource": { "resourceType": "Claim", "id": "63487a3b-54eb-d4f1-35db-828a27b2bc6b", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:48:36-07:00" }, "created": "2012-12-02T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:ca7c6420-6b4c-1afa-a88f-c337a8091d36" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:609e3cb0-2289-eff1-785e-2272fb21c984" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:65fd7200-6352-fa64-e292-711836920653" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 1935.83, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2808.24, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9e8121bc-fe4d-bcce-61b5-29bc16ec4ded", "resource": { "resourceType": "ExplanationOfBenefit", "id": "9e8121bc-fe4d-bcce-61b5-29bc16ec4ded", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "63487a3b-54eb-d4f1-35db-828a27b2bc6b" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2012-12-02T02:48:36-07:00", "end": "2013-12-02T02:48:36-07:00" }, "created": "2012-12-02T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:63487a3b-54eb-d4f1-35db-828a27b2bc6b" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:65fd7200-6352-fa64-e292-711836920653" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 1935.83, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 387.166, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1548.664, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 1935.83, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 1935.83, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2012-12-02T02:33:36-07:00", "end": "2012-12-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2808.24, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 561.648, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2246.592, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2808.24, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2808.24, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3795.2560000000005, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:4887f20d-656d-51e7-fc40-53571416ade2", "resource": { "resourceType": "Encounter", "id": "4887f20d-656d-51e7-fc40-53571416ade2", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:8a8ada95-f956-38d3-b7a1-e7912613a143", "resource": { "resourceType": "Procedure", "id": "8a8ada95-f956-38d3-b7a1-e7912613a143", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4887f20d-656d-51e7-fc40-53571416ade2" }, "performedPeriod": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:9f9ea94c-e27d-5939-2e19-5c9749e84fa4", "resource": { "resourceType": "Procedure", "id": "9f9ea94c-e27d-5939-2e19-5c9749e84fa4", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4887f20d-656d-51e7-fc40-53571416ade2" }, "performedPeriod": { "start": "2013-03-10T03:33:36-06:00", "end": "2013-03-10T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7dc023de-48cd-50fe-41f0-14e627d7e502", "resource": { "resourceType": "Claim", "id": "7dc023de-48cd-50fe-41f0-14e627d7e502", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" }, "created": "2013-03-03T02:52:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:8a8ada95-f956-38d3-b7a1-e7912613a143" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:9f9ea94c-e27d-5939-2e19-5c9749e84fa4" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:4887f20d-656d-51e7-fc40-53571416ade2" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2943.93, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3083.88, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f8310028-1f64-75a6-92cf-ced9e5e00bbf", "resource": { "resourceType": "ExplanationOfBenefit", "id": "f8310028-1f64-75a6-92cf-ced9e5e00bbf", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "7dc023de-48cd-50fe-41f0-14e627d7e502" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-03-03T02:52:36-07:00", "end": "2014-03-03T02:52:36-07:00" }, "created": "2013-03-03T02:52:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:7dc023de-48cd-50fe-41f0-14e627d7e502" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:4887f20d-656d-51e7-fc40-53571416ade2" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2943.93, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 588.786, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2355.144, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2943.93, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2943.93, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-03-03T02:33:36-07:00", "end": "2013-03-03T02:52:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3083.88, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 616.7760000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2467.1040000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3083.88, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3083.88, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4822.248, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9", "resource": { "resourceType": "Encounter", "id": "27c76fea-e7e7-07f3-5557-f98427f482e9", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:8bfe33c0-484e-7dd2-2ef3-02bfa06754c2", "resource": { "resourceType": "Observation", "id": "8bfe33c0-484e-7dd2-2ef3-02bfa06754c2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e1fe6948-9949-0677-ae69-f2850dbf717c", "resource": { "resourceType": "Observation", "id": "e1fe6948-9949-0677-ae69-f2850dbf717c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 2, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:acbb88a8-3eca-acc6-d2c5-e77e6f17b244", "resource": { "resourceType": "Observation", "id": "acbb88a8-3eca-acc6-d2c5-e77e6f17b244", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 82.2, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1dcd4533-caa3-bbf4-e2f4-48da213c8881", "resource": { "resourceType": "Observation", "id": "1dcd4533-caa3-bbf4-e2f4-48da213c8881", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 29.21, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b13a4569-a006-4a6e-ca9b-c15e8d5edd5d", "resource": { "resourceType": "Observation", "id": "b13a4569-a006-4a6e-ca9b-c15e8d5edd5d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 76, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 125, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ca21e621-391f-0ef9-c0dd-57c4ea96e583", "resource": { "resourceType": "Observation", "id": "ca21e621-391f-0ef9-c0dd-57c4ea96e583", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 77, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d2627d00-db83-e41a-3d9e-384125d9ed2a", "resource": { "resourceType": "Observation", "id": "d2627d00-db83-e41a-3d9e-384125d9ed2a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 15, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5f3cce34-a77c-9db7-16ac-035f6cb26052", "resource": { "resourceType": "Observation", "id": "5f3cce34-a77c-9db7-16ac-035f6cb26052", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 101.44, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2fcca95e-9751-14fe-00d6-b613b639934e", "resource": { "resourceType": "Observation", "id": "2fcca95e-9751-14fe-00d6-b613b639934e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 16.21, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3b39e1cc-7111-8e85-ef38-7f135fc70f81", "resource": { "resourceType": "Observation", "id": "3b39e1cc-7111-8e85-ef38-7f135fc70f81", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 1.06, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a30415e8-7cfc-deb1-c595-155eefc1686c", "resource": { "resourceType": "Observation", "id": "a30415e8-7cfc-deb1-c595-155eefc1686c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 10.06, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1cfef9f4-46f9-f05c-3f3f-6420fd38dce7", "resource": { "resourceType": "Observation", "id": "1cfef9f4-46f9-f05c-3f3f-6420fd38dce7", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 142.44, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1fbc19f4-f0d0-91b2-938d-9fbb46b448ae", "resource": { "resourceType": "Observation", "id": "1fbc19f4-f0d0-91b2-938d-9fbb46b448ae", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 4.2, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d67a46ee-ef27-ab5b-60d1-181c221d2a1f", "resource": { "resourceType": "Observation", "id": "d67a46ee-ef27-ab5b-60d1-181c221d2a1f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 105.1, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1e822353-230d-45de-7048-5c549b3fc041", "resource": { "resourceType": "Observation", "id": "1e822353-230d-45de-7048-5c549b3fc041", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 22.86, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c25a82b5-6f2f-0144-7dd7-836c0a208508", "resource": { "resourceType": "Observation", "id": "c25a82b5-6f2f-0144-7dd7-836c0a208508", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 235.39, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f6b690c1-612f-e2fb-eebb-ae7066b887d6", "resource": { "resourceType": "Observation", "id": "f6b690c1-612f-e2fb-eebb-ae7066b887d6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 164.81, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:24aaf36e-a6f2-9dfd-382c-17cca8be6c45", "resource": { "resourceType": "Observation", "id": "24aaf36e-a6f2-9dfd-382c-17cca8be6c45", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 148.69, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1bd65c74-8b7d-b931-232c-43e0a03a1123", "resource": { "resourceType": "Observation", "id": "1bd65c74-8b7d-b931-232c-43e0a03a1123", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 53.74, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:60fd3dfd-0191-3811-72f8-26cdb2fd23bd", "resource": { "resourceType": "Observation", "id": "60fd3dfd-0191-3811-72f8-26cdb2fd23bd", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 4.3, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e95f9698-195b-a98c-20ac-53911bfb2360", "resource": { "resourceType": "Observation", "id": "e95f9698-195b-a98c-20ac-53911bfb2360", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 89.24, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:dc0b0870-8d36-c12d-1e59-8852c01f991c", "resource": { "resourceType": "Observation", "id": "dc0b0870-8d36-c12d-1e59-8852c01f991c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:07daafc5-2531-de7b-b6d4-2bfe80e987cb", "resource": { "resourceType": "Observation", "id": "07daafc5-2531-de7b-b6d4-2bfe80e987cb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "valueQuantity": { "value": 7.3, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:71f96c92-7cb3-26a3-4b85-911383ff5851", "resource": { "resourceType": "Procedure", "id": "71f96c92-7cb3-26a3-4b85-911383ff5851", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "performedPeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7cd2938d-8ede-1454-9f8e-11bc105ec624", "resource": { "resourceType": "MedicationRequest", "id": "7cd2938d-8ede-1454-9f8e-11bc105ec624", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "authoredOn": "2013-03-24T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:a5a83a59-cff8-a1ea-9ce4-591c0a00900e", "resource": { "resourceType": "Claim", "id": "a5a83a59-cff8-a1ea-9ce4-591c0a00900e", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "created": "2013-03-24T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:7cd2938d-8ede-1454-9f8e-11bc105ec624" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:26c592f7-61f6-71ce-ae0f-6dec63fff131", "resource": { "resourceType": "MedicationRequest", "id": "26c592f7-61f6-71ce-ae0f-6dec63fff131", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "authoredOn": "2013-03-24T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:10b70a78-a2e3-991b-5ade-524a03d2264c", "resource": { "resourceType": "Claim", "id": "10b70a78-a2e3-991b-5ade-524a03d2264c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "created": "2013-03-24T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:26c592f7-61f6-71ce-ae0f-6dec63fff131" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:bd591ef9-535e-f085-d959-4ccaf61a833b", "resource": { "resourceType": "Immunization", "id": "bd591ef9-535e-f085-d959-4ccaf61a833b", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "occurrenceDateTime": "2013-03-24T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:272a20cf-6bee-0f76-1356-2ed2b36bdcc4", "resource": { "resourceType": "DiagnosticReport", "id": "272a20cf-6bee-0f76-1356-2ed2b36bdcc4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:5f3cce34-a77c-9db7-16ac-035f6cb26052", "display": "Glucose" }, { "reference": "urn:uuid:2fcca95e-9751-14fe-00d6-b613b639934e", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:3b39e1cc-7111-8e85-ef38-7f135fc70f81", "display": "Creatinine" }, { "reference": "urn:uuid:a30415e8-7cfc-deb1-c595-155eefc1686c", "display": "Calcium" }, { "reference": "urn:uuid:1cfef9f4-46f9-f05c-3f3f-6420fd38dce7", "display": "Sodium" }, { "reference": "urn:uuid:1fbc19f4-f0d0-91b2-938d-9fbb46b448ae", "display": "Potassium" }, { "reference": "urn:uuid:d67a46ee-ef27-ab5b-60d1-181c221d2a1f", "display": "Chloride" }, { "reference": "urn:uuid:1e822353-230d-45de-7048-5c549b3fc041", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:6d5a5301-57f3-5579-2dda-2c25c1104a90", "resource": { "resourceType": "DiagnosticReport", "id": "6d5a5301-57f3-5579-2dda-2c25c1104a90", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" }, "effectiveDateTime": "2013-03-24T03:33:36-06:00", "issued": "2013-03-24T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:c25a82b5-6f2f-0144-7dd7-836c0a208508", "display": "Total Cholesterol" }, { "reference": "urn:uuid:f6b690c1-612f-e2fb-eebb-ae7066b887d6", "display": "Triglycerides" }, { "reference": "urn:uuid:24aaf36e-a6f2-9dfd-382c-17cca8be6c45", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:1bd65c74-8b7d-b931-232c-43e0a03a1123", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:14d91ef5-46b0-a5db-af09-17bdb3fc8576", "resource": { "resourceType": "Claim", "id": "14d91ef5-46b0-a5db-af09-17bdb3fc8576", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "created": "2013-03-24T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:bd591ef9-535e-f085-d959-4ccaf61a833b" } } ], "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:71f96c92-7cb3-26a3-4b85-911383ff5851" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "net": { "value": 588.0, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:cf554f6e-0c47-b98f-cb0b-19dd82a465ff", "resource": { "resourceType": "ExplanationOfBenefit", "id": "cf554f6e-0c47-b98f-cb0b-19dd82a465ff", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "14d91ef5-46b0-a5db-af09-17bdb3fc8576" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-03-24T03:48:36-06:00", "end": "2014-03-24T03:48:36-06:00" }, "created": "2013-03-24T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:14d91ef5-46b0-a5db-af09-17bdb3fc8576" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:27c76fea-e7e7-07f3-5557-f98427f482e9" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "servicedPeriod": { "start": "2013-03-24T03:33:36-06:00", "end": "2013-03-24T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 588.0, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 117.60000000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 470.40000000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 588.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 588.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 582.816, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726", "resource": { "resourceType": "Encounter", "id": "561186b5-4053-2b52-554f-3366e9ba4726", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "EMER" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "50849002", "display": "Emergency room admission (procedure)" } ], "text": "Emergency room admission (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "individual": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } } ], "period": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f", "resource": { "resourceType": "Condition", "id": "46cd6415-e3c1-a20f-1322-2269383b515f", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "resolved" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "284549007", "display": "Laceration of hand" } ], "text": "Laceration of hand" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "onsetDateTime": "2013-04-05T03:59:36-06:00", "abatementDateTime": "2013-04-26T04:25:36-06:00", "recordedDate": "2013-04-05T03:59:36-06:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:b0170c8e-7e4e-bd83-4bf6-7bfc2cc6f1da", "resource": { "resourceType": "Procedure", "id": "b0170c8e-7e4e-bd83-4bf6-7bfc2cc6f1da", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "288086009", "display": "Suture open wound" } ], "text": "Suture open wound" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "performedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:14:36-06:00" }, "reasonReference": [ { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f", "display": "Laceration of hand" } ] }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:cf600ac0-db8b-a924-1c34-0f5139600208", "resource": { "resourceType": "Procedure", "id": "cf600ac0-db8b-a924-1c34-0f5139600208", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "288086009", "display": "Suture open wound" } ], "text": "Suture open wound" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "performedPeriod": { "start": "2013-04-07T03:33:36-06:00", "end": "2013-04-07T03:48:36-06:00" }, "reasonReference": [ { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f", "display": "Laceration of hand" } ] }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:596bba31-0223-793f-3e31-e602d79a635d", "resource": { "resourceType": "Procedure", "id": "596bba31-0223-793f-3e31-e602d79a635d", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "384700001", "display": "Injection of tetanus antitoxin" } ], "text": "Injection of tetanus antitoxin" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "performedPeriod": { "start": "2013-04-05T04:14:36-06:00", "end": "2013-04-05T04:25:36-06:00" }, "reasonReference": [ { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f", "display": "Laceration of hand" } ] }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:dc5cb1ac-bc25-b65f-435f-75b1ee201358", "resource": { "resourceType": "Procedure", "id": "dc5cb1ac-bc25-b65f-435f-75b1ee201358", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "384700001", "display": "Injection of tetanus antitoxin" } ], "text": "Injection of tetanus antitoxin" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "performedPeriod": { "start": "2013-04-07T03:33:36-06:00", "end": "2013-04-07T03:48:36-06:00" }, "reasonReference": [ { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f", "display": "Laceration of hand" } ] }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7509e105-bee3-baf5-fad6-d6d23da4fbc0", "resource": { "resourceType": "MedicationRequest", "id": "7509e105-bee3-baf5-fad6-d6d23da4fbc0", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "849574", "display": "Naproxen sodium 220 MG Oral Tablet" } ], "text": "Naproxen sodium 220 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "authoredOn": "2013-04-05T04:25:36-06:00", "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" }, "dosageInstruction": [ { "sequence": 1, "text": "Take as needed.", "asNeededBoolean": true } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:369b5607-ca93-c735-7bdb-14c07f11032f", "resource": { "resourceType": "Claim", "id": "369b5607-ca93-c735-7bdb-14c07f11032f", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "created": "2013-04-05T04:59:36-06:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:7509e105-bee3-baf5-fad6-d6d23da4fbc0" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "50849002", "display": "Emergency room admission (procedure)" } ], "text": "Emergency room admission (procedure)" }, "encounter": [ { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" } ] } ], "total": { "value": 9.87, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:7ef9dca7-afb6-ef3d-c762-eb16331c21d3", "resource": { "resourceType": "CareTeam", "id": "7ef9dca7-afb6-ef3d-c762-eb16331c21d3", "status": "inactive", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "period": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-26T04:25:36-06:00" }, "participant": [ { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "116154003", "display": "Patient" } ], "text": "Patient" } ], "member": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "223366009", "display": "Healthcare professional (occupation)" } ], "text": "Healthcare professional (occupation)" } ], "member": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "224891009", "display": "Healthcare services (qualifier value)" } ], "text": "Healthcare services (qualifier value)" } ], "member": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } } ], "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "284549007", "display": "Laceration of hand" } ], "text": "Laceration of hand" } ], "managingOrganization": [ { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } ] }, "request": { "method": "POST", "url": "CareTeam" } }, { "fullUrl": "urn:uuid:b39bee79-286d-477c-9501-843f05107e73", "resource": { "resourceType": "CarePlan", "id": "b39bee79-286d-477c-9501-843f05107e73", "text": { "status": "generated", "div": "
Care Plan for Wound care.
Activities:
Care plan is meant to treat Laceration of hand.
" }, "status": "completed", "intent": "order", "category": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "225358003", "display": "Wound care" } ], "text": "Wound care" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" }, "period": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-26T04:25:36-06:00" }, "careTeam": [ { "reference": "urn:uuid:7ef9dca7-afb6-ef3d-c762-eb16331c21d3" } ], "addresses": [ { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f" } ], "activity": [ { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "385949008", "display": "Dressing change management" } ], "text": "Dressing change management" }, "status": "completed", "location": { "display": "SAINT ANNE'S HOSPITAL" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "439830001", "display": "Behavior to prevent infection" } ], "text": "Behavior to prevent infection" }, "status": "completed", "location": { "display": "SAINT ANNE'S HOSPITAL" } } } ] }, "request": { "method": "POST", "url": "CarePlan" } }, { "fullUrl": "urn:uuid:ebeda564-a0b5-f351-da84-0d4d3b22d7b0", "resource": { "resourceType": "Claim", "id": "ebeda564-a0b5-f351-da84-0d4d3b22d7b0", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "created": "2013-04-05T04:59:36-06:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f" } } ], "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:b0170c8e-7e4e-bd83-4bf6-7bfc2cc6f1da" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:cf600ac0-db8b-a924-1c34-0f5139600208" } }, { "sequence": 3, "procedureReference": { "reference": "urn:uuid:596bba31-0223-793f-3e31-e602d79a635d" } }, { "sequence": 4, "procedureReference": { "reference": "urn:uuid:dc5cb1ac-bc25-b65f-435f-75b1ee201358" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "50849002", "display": "Emergency room admission (procedure)" } ], "text": "Emergency room admission (procedure)" }, "encounter": [ { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "284549007", "display": "Laceration of hand" } ], "text": "Laceration of hand" } }, { "sequence": 3, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "288086009", "display": "Suture open wound" } ], "text": "Suture open wound" }, "net": { "value": 13262.2, "currency": "USD" } }, { "sequence": 4, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "288086009", "display": "Suture open wound" } ], "text": "Suture open wound" }, "net": { "value": 14761.6, "currency": "USD" } }, { "sequence": 5, "procedureSequence": [ 3 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "384700001", "display": "Injection of tetanus antitoxin" } ], "text": "Injection of tetanus antitoxin" }, "net": { "value": 4917.31, "currency": "USD" } }, { "sequence": 6, "procedureSequence": [ 4 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "384700001", "display": "Injection of tetanus antitoxin" } ], "text": "Injection of tetanus antitoxin" }, "net": { "value": 3012.39, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:3838a598-084e-f9f2-3bb4-3308af11bd8d", "resource": { "resourceType": "ExplanationOfBenefit", "id": "3838a598-084e-f9f2-3bb4-3308af11bd8d", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "performer": [ { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "ebeda564-a0b5-f351-da84-0d4d3b22d7b0" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-04-05T04:59:36-06:00", "end": "2014-04-05T04:59:36-06:00" }, "created": "2013-04-05T04:59:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:ebeda564-a0b5-f351-da84-0d4d3b22d7b0" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:46cd6415-e3c1-a20f-1322-2269383b515f" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "50849002", "display": "Emergency room admission (procedure)" } ], "text": "Emergency room admission (procedure)" }, "servicedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] }, "encounter": [ { "reference": "urn:uuid:561186b5-4053-2b52-554f-3366e9ba4726" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "284549007", "display": "Laceration of hand" } ], "text": "Laceration of hand" }, "servicedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] } }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "288086009", "display": "Suture open wound" } ], "text": "Suture open wound" }, "servicedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] }, "net": { "value": 13262.2, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 2652.4400000000007, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 10609.760000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 13262.2, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 13262.2, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 4, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "288086009", "display": "Suture open wound" } ], "text": "Suture open wound" }, "servicedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] }, "net": { "value": 14761.6, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 2952.32, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 11809.28, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 14761.6, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 14761.6, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 5, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "384700001", "display": "Injection of tetanus antitoxin" } ], "text": "Injection of tetanus antitoxin" }, "servicedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] }, "net": { "value": 4917.31, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 983.4620000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3933.8480000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4917.31, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4917.31, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 6, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "384700001", "display": "Injection of tetanus antitoxin" } ], "text": "Injection of tetanus antitoxin" }, "servicedPeriod": { "start": "2013-04-05T03:59:36-06:00", "end": "2013-04-05T04:59:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "20", "display": "Urgent Care Facility" } ] }, "net": { "value": 3012.39, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 602.478, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2409.912, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3012.39, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3012.39, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 28762.800000000003, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:08cc32bf-65c3-058f-6e1c-dc4aa5c05f31", "resource": { "resourceType": "Encounter", "id": "08cc32bf-65c3-058f-6e1c-dc4aa5c05f31", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-04-27T03:33:36-06:00", "end": "2013-04-27T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2013-04-27T03:33:36-06:00", "end": "2013-04-27T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:b874e472-4a71-70b6-ecaf-b58c0c89f0ea", "resource": { "resourceType": "MedicationRequest", "id": "b874e472-4a71-70b6-ecaf-b58c0c89f0ea", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "748962", "display": "Camila 28 Day Pack" } ], "text": "Camila 28 Day Pack" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:08cc32bf-65c3-058f-6e1c-dc4aa5c05f31" }, "authoredOn": "2013-04-27T03:33:36-06:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1a56aded-4d3f-45f8-1dff-61b8e356ee75", "resource": { "resourceType": "Claim", "id": "1a56aded-4d3f-45f8-1dff-61b8e356ee75", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-04-27T03:33:36-06:00", "end": "2013-04-27T03:48:36-06:00" }, "created": "2013-04-27T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:b874e472-4a71-70b6-ecaf-b58c0c89f0ea" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:08cc32bf-65c3-058f-6e1c-dc4aa5c05f31" } ] } ], "total": { "value": 30.11, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:cd332d06-0b66-15cd-66ab-64492b4dbd7c", "resource": { "resourceType": "Claim", "id": "cd332d06-0b66-15cd-66ab-64492b4dbd7c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-04-27T03:33:36-06:00", "end": "2013-04-27T03:48:36-06:00" }, "created": "2013-04-27T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:08cc32bf-65c3-058f-6e1c-dc4aa5c05f31" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d851745a-b6bf-c6b4-f5d8-1890978c745f", "resource": { "resourceType": "ExplanationOfBenefit", "id": "d851745a-b6bf-c6b4-f5d8-1890978c745f", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "cd332d06-0b66-15cd-66ab-64492b4dbd7c" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-04-27T03:48:36-06:00", "end": "2014-04-27T03:48:36-06:00" }, "created": "2013-04-27T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:cd332d06-0b66-15cd-66ab-64492b4dbd7c" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "servicedPeriod": { "start": "2013-04-27T03:33:36-06:00", "end": "2013-04-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:08cc32bf-65c3-058f-6e1c-dc4aa5c05f31" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:07dbc4ca-2d3c-c39e-6c5e-4a567ff1c937", "resource": { "resourceType": "Encounter", "id": "07dbc4ca-2d3c-c39e-6c5e-4a567ff1c937", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:a2daea24-d824-2c8c-a603-43a381d76d17", "resource": { "resourceType": "Procedure", "id": "a2daea24-d824-2c8c-a603-43a381d76d17", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:07dbc4ca-2d3c-c39e-6c5e-4a567ff1c937" }, "performedPeriod": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:44:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:633e2f25-e993-ed76-cfc3-63dca0005794", "resource": { "resourceType": "Procedure", "id": "633e2f25-e993-ed76-cfc3-63dca0005794", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:07dbc4ca-2d3c-c39e-6c5e-4a567ff1c937" }, "performedPeriod": { "start": "2013-06-09T03:33:36-06:00", "end": "2013-06-09T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:3bda1c9f-e5b0-df6f-d446-94142621c687", "resource": { "resourceType": "Claim", "id": "3bda1c9f-e5b0-df6f-d446-94142621c687", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:48:36-06:00" }, "created": "2013-06-02T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:a2daea24-d824-2c8c-a603-43a381d76d17" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:633e2f25-e993-ed76-cfc3-63dca0005794" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:07dbc4ca-2d3c-c39e-6c5e-4a567ff1c937" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2408.83, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2599.21, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:103777f7-0955-5805-d137-2c9aad95f611", "resource": { "resourceType": "ExplanationOfBenefit", "id": "103777f7-0955-5805-d137-2c9aad95f611", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "3bda1c9f-e5b0-df6f-d446-94142621c687" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-06-02T03:48:36-06:00", "end": "2014-06-02T03:48:36-06:00" }, "created": "2013-06-02T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:3bda1c9f-e5b0-df6f-d446-94142621c687" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:07dbc4ca-2d3c-c39e-6c5e-4a567ff1c937" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2408.83, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 481.766, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1927.064, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2408.83, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2408.83, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-06-02T03:33:36-06:00", "end": "2013-06-02T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2599.21, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 519.842, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2079.368, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2599.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2599.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4006.432, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:61af34d2-040e-caed-62a9-1fda3c33d4de", "resource": { "resourceType": "Encounter", "id": "61af34d2-040e-caed-62a9-1fda3c33d4de", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:63e74e0e-7521-61e0-d648-7e61f43738ae", "resource": { "resourceType": "Procedure", "id": "63e74e0e-7521-61e0-d648-7e61f43738ae", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:61af34d2-040e-caed-62a9-1fda3c33d4de" }, "performedPeriod": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:46:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:638fb9f4-a552-aebf-d3e3-a84150d95711", "resource": { "resourceType": "Procedure", "id": "638fb9f4-a552-aebf-d3e3-a84150d95711", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:61af34d2-040e-caed-62a9-1fda3c33d4de" }, "performedPeriod": { "start": "2013-09-08T03:33:36-06:00", "end": "2013-09-08T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:dc7dedaf-6faa-dbfd-5d56-bf969ef18671", "resource": { "resourceType": "Claim", "id": "dc7dedaf-6faa-dbfd-5d56-bf969ef18671", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:48:36-06:00" }, "created": "2013-09-01T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:63e74e0e-7521-61e0-d648-7e61f43738ae" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:638fb9f4-a552-aebf-d3e3-a84150d95711" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:61af34d2-040e-caed-62a9-1fda3c33d4de" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3955.0, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3042.27, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ab38a3f8-346d-ff3d-aa23-3068aff28b55", "resource": { "resourceType": "ExplanationOfBenefit", "id": "ab38a3f8-346d-ff3d-aa23-3068aff28b55", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "dc7dedaf-6faa-dbfd-5d56-bf969ef18671" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-09-01T03:48:36-06:00", "end": "2014-09-01T03:48:36-06:00" }, "created": "2013-09-01T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:dc7dedaf-6faa-dbfd-5d56-bf969ef18671" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:61af34d2-040e-caed-62a9-1fda3c33d4de" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3955.0, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 791.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3164.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3955.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3955.0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-09-01T03:33:36-06:00", "end": "2013-09-01T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3042.27, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 608.4540000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2433.8160000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3042.27, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3042.27, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5597.816000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:08ecdb12-f185-7239-dc57-61b3a018f5e3", "resource": { "resourceType": "Encounter", "id": "08ecdb12-f185-7239-dc57-61b3a018f5e3", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:42e03dfd-3cab-55e6-ba17-e3c4a2e353a7", "resource": { "resourceType": "Procedure", "id": "42e03dfd-3cab-55e6-ba17-e3c4a2e353a7", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:08ecdb12-f185-7239-dc57-61b3a018f5e3" }, "performedPeriod": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:9f046ce6-4c28-a3d5-ea5c-afc6db353992", "resource": { "resourceType": "Procedure", "id": "9f046ce6-4c28-a3d5-ea5c-afc6db353992", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:08ecdb12-f185-7239-dc57-61b3a018f5e3" }, "performedPeriod": { "start": "2013-12-08T02:33:36-07:00", "end": "2013-12-08T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:9191d8db-8d18-71dc-f18a-4c9d4b126a44", "resource": { "resourceType": "Claim", "id": "9191d8db-8d18-71dc-f18a-4c9d4b126a44", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" }, "created": "2013-12-01T02:50:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:42e03dfd-3cab-55e6-ba17-e3c4a2e353a7" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:9f046ce6-4c28-a3d5-ea5c-afc6db353992" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:08ecdb12-f185-7239-dc57-61b3a018f5e3" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2937.12, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3957.18, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:32c826c9-7029-4bf5-acb7-ecf261ef9c8d", "resource": { "resourceType": "ExplanationOfBenefit", "id": "32c826c9-7029-4bf5-acb7-ecf261ef9c8d", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "9191d8db-8d18-71dc-f18a-4c9d4b126a44" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2013-12-01T02:50:36-07:00", "end": "2014-12-01T02:50:36-07:00" }, "created": "2013-12-01T02:50:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:9191d8db-8d18-71dc-f18a-4c9d4b126a44" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:08ecdb12-f185-7239-dc57-61b3a018f5e3" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2937.12, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 587.424, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2349.696, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2937.12, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2937.12, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2013-12-01T02:33:36-07:00", "end": "2013-12-01T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3957.18, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 791.436, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3165.744, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3957.18, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3957.18, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5515.4400000000009, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:e35d4d9f-31ff-c865-fdf0-da8ce46aa631", "resource": { "resourceType": "Encounter", "id": "e35d4d9f-31ff-c865-fdf0-da8ce46aa631", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d103e3d0-f0eb-ba20-01d0-c2e91d140eeb", "resource": { "resourceType": "Procedure", "id": "d103e3d0-f0eb-ba20-01d0-c2e91d140eeb", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e35d4d9f-31ff-c865-fdf0-da8ce46aa631" }, "performedPeriod": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:46:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:d6045003-80d3-a56b-94bf-b90408104fb4", "resource": { "resourceType": "Procedure", "id": "d6045003-80d3-a56b-94bf-b90408104fb4", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e35d4d9f-31ff-c865-fdf0-da8ce46aa631" }, "performedPeriod": { "start": "2014-03-09T03:33:36-06:00", "end": "2014-03-09T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:366bd106-2650-5ac3-4d0c-00768af74244", "resource": { "resourceType": "Claim", "id": "366bd106-2650-5ac3-4d0c-00768af74244", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:48:36-07:00" }, "created": "2014-03-02T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:d103e3d0-f0eb-ba20-01d0-c2e91d140eeb" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:d6045003-80d3-a56b-94bf-b90408104fb4" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:e35d4d9f-31ff-c865-fdf0-da8ce46aa631" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2393.37, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3184.04, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6e0f90fe-dd2c-dbfd-dc6c-f5c59bbc84d8", "resource": { "resourceType": "ExplanationOfBenefit", "id": "6e0f90fe-dd2c-dbfd-dc6c-f5c59bbc84d8", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "366bd106-2650-5ac3-4d0c-00768af74244" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-03-02T02:48:36-07:00", "end": "2015-03-02T02:48:36-07:00" }, "created": "2014-03-02T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:366bd106-2650-5ac3-4d0c-00768af74244" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:e35d4d9f-31ff-c865-fdf0-da8ce46aa631" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2393.37, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 478.674, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1914.696, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2393.37, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2393.37, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-03-02T02:33:36-07:00", "end": "2014-03-02T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3184.04, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 636.808, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2547.232, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3184.04, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3184.04, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4461.928, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636", "resource": { "resourceType": "Encounter", "id": "7bd137e4-9b1c-efae-185b-a7f954d3d636", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:6b75b135-4fbf-06cc-9a62-f76b7670adee", "resource": { "resourceType": "Observation", "id": "6b75b135-4fbf-06cc-9a62-f76b7670adee", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d73618df-4d24-5895-f952-4de15cf094e1", "resource": { "resourceType": "Observation", "id": "d73618df-4d24-5895-f952-4de15cf094e1", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 2, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:703e0380-8264-58af-575b-43de67740207", "resource": { "resourceType": "Observation", "id": "703e0380-8264-58af-575b-43de67740207", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 83.9, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:80c995d8-226e-eb90-48d3-c7338fa1bf6c", "resource": { "resourceType": "Observation", "id": "80c995d8-226e-eb90-48d3-c7338fa1bf6c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 29.83, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:aec91f72-36a2-fd1f-a0db-96de38cd1b7a", "resource": { "resourceType": "Observation", "id": "aec91f72-36a2-fd1f-a0db-96de38cd1b7a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 85, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 109, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e2172ca8-5ce5-5d9b-45bd-280d31776a7e", "resource": { "resourceType": "Observation", "id": "e2172ca8-5ce5-5d9b-45bd-280d31776a7e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 84, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:20a943ca-d64e-08bc-ebcf-48807aa99c64", "resource": { "resourceType": "Observation", "id": "20a943ca-d64e-08bc-ebcf-48807aa99c64", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 15, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f4f2c19c-c440-3b17-2c1e-12179d2aeac5", "resource": { "resourceType": "Observation", "id": "f4f2c19c-c440-3b17-2c1e-12179d2aeac5", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 118.59, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ba348903-5023-f9c6-6177-03ab6165e323", "resource": { "resourceType": "Observation", "id": "ba348903-5023-f9c6-6177-03ab6165e323", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 9.55, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1eeb79f6-b43d-f047-a3dd-5317641d5172", "resource": { "resourceType": "Observation", "id": "1eeb79f6-b43d-f047-a3dd-5317641d5172", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 0.96, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:aa3ae3c3-0c8c-c8a4-0d28-cc99c426ceda", "resource": { "resourceType": "Observation", "id": "aa3ae3c3-0c8c-c8a4-0d28-cc99c426ceda", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 9, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e54f666b-3b61-61d4-aae2-d3608c78f8bb", "resource": { "resourceType": "Observation", "id": "e54f666b-3b61-61d4-aae2-d3608c78f8bb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 137.96, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:7889f76a-68d9-8861-769a-575e563793f1", "resource": { "resourceType": "Observation", "id": "7889f76a-68d9-8861-769a-575e563793f1", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 4.66, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8d09fda0-fcbb-154a-c820-d45e38482058", "resource": { "resourceType": "Observation", "id": "8d09fda0-fcbb-154a-c820-d45e38482058", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 107.71, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c128b88b-d1a7-972a-b1af-ae59899da092", "resource": { "resourceType": "Observation", "id": "c128b88b-d1a7-972a-b1af-ae59899da092", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 25.54, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:18e766b5-957e-e999-e616-7f0c59129a07", "resource": { "resourceType": "Observation", "id": "18e766b5-957e-e999-e616-7f0c59129a07", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 219.14, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5d74df6f-4749-5ed1-5208-28c52594912d", "resource": { "resourceType": "Observation", "id": "5d74df6f-4749-5ed1-5208-28c52594912d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 173.18, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:200693ba-dd68-5f94-aca5-c27d33d48609", "resource": { "resourceType": "Observation", "id": "200693ba-dd68-5f94-aca5-c27d33d48609", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 142.92, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:078c2a8b-d156-a54d-7dc3-b12b7fe434f4", "resource": { "resourceType": "Observation", "id": "078c2a8b-d156-a54d-7dc3-b12b7fe434f4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 41.58, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a5842c34-772f-7275-9356-825761601fa2", "resource": { "resourceType": "Observation", "id": "a5842c34-772f-7275-9356-825761601fa2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 9.4, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e7ab7114-28c6-6d38-903a-5bec7442a260", "resource": { "resourceType": "Observation", "id": "e7ab7114-28c6-6d38-903a-5bec7442a260", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 157.77, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:71a84798-cc90-0057-2e61-1551a77c999c", "resource": { "resourceType": "Observation", "id": "71a84798-cc90-0057-2e61-1551a77c999c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:066d8568-aa34-664f-5aa0-4dbba9345baa", "resource": { "resourceType": "Observation", "id": "066d8568-aa34-664f-5aa0-4dbba9345baa", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "valueQuantity": { "value": 7.46, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6c20f7d7-bfa5-c2bb-6a1a-13be7f540ac5", "resource": { "resourceType": "Procedure", "id": "6c20f7d7-bfa5-c2bb-6a1a-13be7f540ac5", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "performedPeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:5213e7a0-7433-edf6-15cf-f2216e1c8353", "resource": { "resourceType": "MedicationRequest", "id": "5213e7a0-7433-edf6-15cf-f2216e1c8353", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "authoredOn": "2014-03-30T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:1e13a3d1-119e-d704-8199-75fa5e026a6c", "resource": { "resourceType": "Claim", "id": "1e13a3d1-119e-d704-8199-75fa5e026a6c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "created": "2014-03-30T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:5213e7a0-7433-edf6-15cf-f2216e1c8353" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:c0434806-6fd2-9fb2-85b4-81f8826f209d", "resource": { "resourceType": "MedicationRequest", "id": "c0434806-6fd2-9fb2-85b4-81f8826f209d", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "authoredOn": "2014-03-30T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:d20f31d8-bd06-d6fb-7eb7-02fddc579ce8", "resource": { "resourceType": "Claim", "id": "d20f31d8-bd06-d6fb-7eb7-02fddc579ce8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "created": "2014-03-30T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:c0434806-6fd2-9fb2-85b4-81f8826f209d" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:18ddd997-e3ac-75ac-a40e-d9f16237740f", "resource": { "resourceType": "Immunization", "id": "18ddd997-e3ac-75ac-a40e-d9f16237740f", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "occurrenceDateTime": "2014-03-30T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:bf290238-482c-814b-fab6-0ed1ab1e9011", "resource": { "resourceType": "DiagnosticReport", "id": "bf290238-482c-814b-fab6-0ed1ab1e9011", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:f4f2c19c-c440-3b17-2c1e-12179d2aeac5", "display": "Glucose" }, { "reference": "urn:uuid:ba348903-5023-f9c6-6177-03ab6165e323", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:1eeb79f6-b43d-f047-a3dd-5317641d5172", "display": "Creatinine" }, { "reference": "urn:uuid:aa3ae3c3-0c8c-c8a4-0d28-cc99c426ceda", "display": "Calcium" }, { "reference": "urn:uuid:e54f666b-3b61-61d4-aae2-d3608c78f8bb", "display": "Sodium" }, { "reference": "urn:uuid:7889f76a-68d9-8861-769a-575e563793f1", "display": "Potassium" }, { "reference": "urn:uuid:8d09fda0-fcbb-154a-c820-d45e38482058", "display": "Chloride" }, { "reference": "urn:uuid:c128b88b-d1a7-972a-b1af-ae59899da092", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:21e57489-1c33-7935-658e-a10e48645bf4", "resource": { "resourceType": "DiagnosticReport", "id": "21e57489-1c33-7935-658e-a10e48645bf4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" }, "effectiveDateTime": "2014-03-30T03:33:36-06:00", "issued": "2014-03-30T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:18e766b5-957e-e999-e616-7f0c59129a07", "display": "Total Cholesterol" }, { "reference": "urn:uuid:5d74df6f-4749-5ed1-5208-28c52594912d", "display": "Triglycerides" }, { "reference": "urn:uuid:200693ba-dd68-5f94-aca5-c27d33d48609", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:078c2a8b-d156-a54d-7dc3-b12b7fe434f4", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:4bceb9ab-6263-f205-a83a-8914d97b67c5", "resource": { "resourceType": "Claim", "id": "4bceb9ab-6263-f205-a83a-8914d97b67c5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "created": "2014-03-30T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:18ddd997-e3ac-75ac-a40e-d9f16237740f" } } ], "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:6c20f7d7-bfa5-c2bb-6a1a-13be7f540ac5" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "net": { "value": 651.47, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:378f88bf-a60d-033c-d179-bf27f38cc8dd", "resource": { "resourceType": "ExplanationOfBenefit", "id": "378f88bf-a60d-033c-d179-bf27f38cc8dd", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "4bceb9ab-6263-f205-a83a-8914d97b67c5" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-03-30T03:48:36-06:00", "end": "2015-03-30T03:48:36-06:00" }, "created": "2014-03-30T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:4bceb9ab-6263-f205-a83a-8914d97b67c5" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:7bd137e4-9b1c-efae-185b-a7f954d3d636" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "servicedPeriod": { "start": "2014-03-30T03:33:36-06:00", "end": "2014-03-30T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 651.47, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 130.294, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 521.176, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 651.47, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 651.47, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 633.5920000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:bc16dbe1-f527-6b1e-e861-5b775332ba65", "resource": { "resourceType": "Encounter", "id": "bc16dbe1-f527-6b1e-e861-5b775332ba65", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2014-04-22T03:33:36-06:00", "end": "2014-04-22T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2014-04-22T03:33:36-06:00", "end": "2014-04-22T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d6f4e056-91a6-8cda-b15c-236a5e1e421b", "resource": { "resourceType": "MedicationRequest", "id": "d6f4e056-91a6-8cda-b15c-236a5e1e421b", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "749762", "display": "Seasonique 91 Day Pack" } ], "text": "Seasonique 91 Day Pack" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bc16dbe1-f527-6b1e-e861-5b775332ba65" }, "authoredOn": "2014-04-22T03:33:36-06:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:8e9a3603-3058-aced-4e16-183da4ebdd55", "resource": { "resourceType": "Claim", "id": "8e9a3603-3058-aced-4e16-183da4ebdd55", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-04-22T03:33:36-06:00", "end": "2014-04-22T03:48:36-06:00" }, "created": "2014-04-22T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:d6f4e056-91a6-8cda-b15c-236a5e1e421b" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:bc16dbe1-f527-6b1e-e861-5b775332ba65" } ] } ], "total": { "value": 47.72, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:4507321d-3964-0fc7-9379-dad407277a46", "resource": { "resourceType": "Claim", "id": "4507321d-3964-0fc7-9379-dad407277a46", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2014-04-22T03:33:36-06:00", "end": "2014-04-22T03:48:36-06:00" }, "created": "2014-04-22T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:bc16dbe1-f527-6b1e-e861-5b775332ba65" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:62201924-ff24-dead-7bff-f8c504c0417f", "resource": { "resourceType": "ExplanationOfBenefit", "id": "62201924-ff24-dead-7bff-f8c504c0417f", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "4507321d-3964-0fc7-9379-dad407277a46" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-04-22T03:48:36-06:00", "end": "2015-04-22T03:48:36-06:00" }, "created": "2014-04-22T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:4507321d-3964-0fc7-9379-dad407277a46" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "servicedPeriod": { "start": "2014-04-22T03:33:36-06:00", "end": "2014-04-22T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:bc16dbe1-f527-6b1e-e861-5b775332ba65" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:46b68415-0e09-f6e1-b7fd-76b91d30f3b8", "resource": { "resourceType": "Encounter", "id": "46b68415-0e09-f6e1-b7fd-76b91d30f3b8", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:7da764d5-c14d-0701-3aa0-2bf955a9dfd1", "resource": { "resourceType": "Procedure", "id": "7da764d5-c14d-0701-3aa0-2bf955a9dfd1", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:46b68415-0e09-f6e1-b7fd-76b91d30f3b8" }, "performedPeriod": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:d2705df4-ff44-9eac-c61c-c340d8d5b513", "resource": { "resourceType": "Procedure", "id": "d2705df4-ff44-9eac-c61c-c340d8d5b513", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:46b68415-0e09-f6e1-b7fd-76b91d30f3b8" }, "performedPeriod": { "start": "2014-06-08T03:33:36-06:00", "end": "2014-06-08T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:fb966196-1ad5-146b-fd7b-74da5ca2b5ba", "resource": { "resourceType": "Claim", "id": "fb966196-1ad5-146b-fd7b-74da5ca2b5ba", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" }, "created": "2014-06-01T03:52:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:7da764d5-c14d-0701-3aa0-2bf955a9dfd1" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:d2705df4-ff44-9eac-c61c-c340d8d5b513" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:46b68415-0e09-f6e1-b7fd-76b91d30f3b8" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3410.09, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2128.21, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:be62cba8-306f-65cd-d3ad-cde7990e0db7", "resource": { "resourceType": "ExplanationOfBenefit", "id": "be62cba8-306f-65cd-d3ad-cde7990e0db7", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "fb966196-1ad5-146b-fd7b-74da5ca2b5ba" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-06-01T03:52:36-06:00", "end": "2015-06-01T03:52:36-06:00" }, "created": "2014-06-01T03:52:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:fb966196-1ad5-146b-fd7b-74da5ca2b5ba" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:46b68415-0e09-f6e1-b7fd-76b91d30f3b8" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3410.09, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 682.018, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2728.072, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3410.09, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3410.09, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-06-01T03:33:36-06:00", "end": "2014-06-01T03:52:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2128.21, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 425.64200000000008, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1702.5680000000003, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2128.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2128.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4430.64, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:281b6b5a-2a5b-75d3-4f69-18ffa68751b1", "resource": { "resourceType": "Encounter", "id": "281b6b5a-2a5b-75d3-4f69-18ffa68751b1", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:b22d2fcb-cbfd-4d8e-5ee6-3bfcdf5e6a4d", "resource": { "resourceType": "Procedure", "id": "b22d2fcb-cbfd-4d8e-5ee6-3bfcdf5e6a4d", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:281b6b5a-2a5b-75d3-4f69-18ffa68751b1" }, "performedPeriod": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:da086c09-7c9b-4306-c761-1f13ae0e6fae", "resource": { "resourceType": "Procedure", "id": "da086c09-7c9b-4306-c761-1f13ae0e6fae", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:281b6b5a-2a5b-75d3-4f69-18ffa68751b1" }, "performedPeriod": { "start": "2014-09-07T03:33:36-06:00", "end": "2014-09-07T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:0de8e634-f225-2a5e-573e-f1241e5c393f", "resource": { "resourceType": "Claim", "id": "0de8e634-f225-2a5e-573e-f1241e5c393f", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" }, "created": "2014-08-31T03:50:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:b22d2fcb-cbfd-4d8e-5ee6-3bfcdf5e6a4d" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:da086c09-7c9b-4306-c761-1f13ae0e6fae" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:281b6b5a-2a5b-75d3-4f69-18ffa68751b1" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4228.92, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3216.56, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6cb32601-a1da-f535-3863-dd51a967a5af", "resource": { "resourceType": "ExplanationOfBenefit", "id": "6cb32601-a1da-f535-3863-dd51a967a5af", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "0de8e634-f225-2a5e-573e-f1241e5c393f" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-08-31T03:50:36-06:00", "end": "2015-08-31T03:50:36-06:00" }, "created": "2014-08-31T03:50:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:0de8e634-f225-2a5e-573e-f1241e5c393f" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:281b6b5a-2a5b-75d3-4f69-18ffa68751b1" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4228.92, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 845.7840000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3383.1360000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4228.92, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4228.92, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-08-31T03:33:36-06:00", "end": "2014-08-31T03:50:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3216.56, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 643.312, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2573.248, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3216.56, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3216.56, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5956.384, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:0bb3b667-f1b3-644e-37b6-05d5693adf3d", "resource": { "resourceType": "Encounter", "id": "0bb3b667-f1b3-644e-37b6-05d5693adf3d", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:88a44e95-6049-af72-c854-d80e07532035", "resource": { "resourceType": "Procedure", "id": "88a44e95-6049-af72-c854-d80e07532035", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0bb3b667-f1b3-644e-37b6-05d5693adf3d" }, "performedPeriod": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:44:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:1c261621-3423-4794-81e9-0ddb7752bbb9", "resource": { "resourceType": "Procedure", "id": "1c261621-3423-4794-81e9-0ddb7752bbb9", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0bb3b667-f1b3-644e-37b6-05d5693adf3d" }, "performedPeriod": { "start": "2014-12-07T02:33:36-07:00", "end": "2014-12-07T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:181f7885-1c8d-1736-7ae2-f02b0bc46ec4", "resource": { "resourceType": "Claim", "id": "181f7885-1c8d-1736-7ae2-f02b0bc46ec4", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:48:36-07:00" }, "created": "2014-11-30T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:88a44e95-6049-af72-c854-d80e07532035" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:1c261621-3423-4794-81e9-0ddb7752bbb9" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:0bb3b667-f1b3-644e-37b6-05d5693adf3d" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3575.8, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2902.11, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:615f3bcc-8861-e50c-9ec1-aed51ad43d6c", "resource": { "resourceType": "ExplanationOfBenefit", "id": "615f3bcc-8861-e50c-9ec1-aed51ad43d6c", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "181f7885-1c8d-1736-7ae2-f02b0bc46ec4" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2014-11-30T02:48:36-07:00", "end": "2015-11-30T02:48:36-07:00" }, "created": "2014-11-30T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:181f7885-1c8d-1736-7ae2-f02b0bc46ec4" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:0bb3b667-f1b3-644e-37b6-05d5693adf3d" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3575.8, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 715.1600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2860.6400000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3575.8, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3575.8, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2014-11-30T02:33:36-07:00", "end": "2014-11-30T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2902.11, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 580.422, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2321.688, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2902.11, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2902.11, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5182.328, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:9bcdce8d-3801-bcde-86d7-e1a52c626066", "resource": { "resourceType": "Encounter", "id": "9bcdce8d-3801-bcde-86d7-e1a52c626066", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:37910110-c1dc-82b2-46ae-86b83e1906cf", "resource": { "resourceType": "Procedure", "id": "37910110-c1dc-82b2-46ae-86b83e1906cf", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9bcdce8d-3801-bcde-86d7-e1a52c626066" }, "performedPeriod": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:45:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:93159dd6-d270-1429-7d69-1208c575f029", "resource": { "resourceType": "Procedure", "id": "93159dd6-d270-1429-7d69-1208c575f029", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:9bcdce8d-3801-bcde-86d7-e1a52c626066" }, "performedPeriod": { "start": "2015-03-08T03:33:36-06:00", "end": "2015-03-08T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:ed359540-f3bc-9c29-18a2-624ab74522a3", "resource": { "resourceType": "Claim", "id": "ed359540-f3bc-9c29-18a2-624ab74522a3", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:48:36-07:00" }, "created": "2015-03-01T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:37910110-c1dc-82b2-46ae-86b83e1906cf" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:93159dd6-d270-1429-7d69-1208c575f029" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:9bcdce8d-3801-bcde-86d7-e1a52c626066" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2096.42, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2286.08, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d2e8b085-9337-fcbc-e463-aef7801a419c", "resource": { "resourceType": "ExplanationOfBenefit", "id": "d2e8b085-9337-fcbc-e463-aef7801a419c", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "ed359540-f3bc-9c29-18a2-624ab74522a3" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-03-01T02:48:36-07:00", "end": "2016-03-01T02:48:36-07:00" }, "created": "2015-03-01T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:ed359540-f3bc-9c29-18a2-624ab74522a3" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:9bcdce8d-3801-bcde-86d7-e1a52c626066" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2096.42, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 419.28400000000007, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1677.1360000000003, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2096.42, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2096.42, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-03-01T02:33:36-07:00", "end": "2015-03-01T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2286.08, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 457.216, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1828.864, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2286.08, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2286.08, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3506.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869", "resource": { "resourceType": "Encounter", "id": "2858ffe8-ea73-7337-f453-c3a8c62a4869", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:7513782d-dc34-da9e-654e-1ca84abfad56", "resource": { "resourceType": "Observation", "id": "7513782d-dc34-da9e-654e-1ca84abfad56", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f9a07347-e7f7-3046-0176-b8c2dc9f30eb", "resource": { "resourceType": "Observation", "id": "f9a07347-e7f7-3046-0176-b8c2dc9f30eb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 4, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:81570856-0edc-3ebc-1cd8-b4621553dd6f", "resource": { "resourceType": "Observation", "id": "81570856-0edc-3ebc-1cd8-b4621553dd6f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:48f96ed0-1153-92e5-0aeb-01dc65bcfab1", "resource": { "resourceType": "Observation", "id": "48f96ed0-1153-92e5-0aeb-01dc65bcfab1", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:90d7e0fd-5a59-1f66-e737-d3049aa0fa05", "resource": { "resourceType": "Observation", "id": "90d7e0fd-5a59-1f66-e737-d3049aa0fa05", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 79, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 118, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1b1ab1a8-6e70-3245-fa18-880a9cb49e8d", "resource": { "resourceType": "Observation", "id": "1b1ab1a8-6e70-3245-fa18-880a9cb49e8d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 84, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:73ab8911-dfa5-a0d0-bf41-378260b5e5b9", "resource": { "resourceType": "Observation", "id": "73ab8911-dfa5-a0d0-bf41-378260b5e5b9", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 16, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2a40fd29-d72e-4dbd-cbf4-23bc282e7410", "resource": { "resourceType": "Observation", "id": "2a40fd29-d72e-4dbd-cbf4-23bc282e7410", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 106.01, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4f8ef8fa-d6e5-6d92-6766-b15dc2698a2f", "resource": { "resourceType": "Observation", "id": "4f8ef8fa-d6e5-6d92-6766-b15dc2698a2f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 15.35, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6fd1a764-ab40-2d47-4e66-b32f1b65c612", "resource": { "resourceType": "Observation", "id": "6fd1a764-ab40-2d47-4e66-b32f1b65c612", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 1.17, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c60fd50e-c782-9f29-9ce8-1f33444b3492", "resource": { "resourceType": "Observation", "id": "c60fd50e-c782-9f29-9ce8-1f33444b3492", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 9, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:87ccfd9b-bc5c-1200-5210-80f83272772e", "resource": { "resourceType": "Observation", "id": "87ccfd9b-bc5c-1200-5210-80f83272772e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 140.11, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6fb2781b-d2cf-3674-06d6-bd2daf92020d", "resource": { "resourceType": "Observation", "id": "6fb2781b-d2cf-3674-06d6-bd2daf92020d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 4.4, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4a3a76c4-64ac-b6ac-c1a2-fa7c9b72b643", "resource": { "resourceType": "Observation", "id": "4a3a76c4-64ac-b6ac-c1a2-fa7c9b72b643", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 101.25, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:60decde1-872d-2437-ebc3-c3936ddd5c53", "resource": { "resourceType": "Observation", "id": "60decde1-872d-2437-ebc3-c3936ddd5c53", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 23.91, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:91f8b60a-5da1-602f-3d4a-b67b6286c2f4", "resource": { "resourceType": "Observation", "id": "91f8b60a-5da1-602f-3d4a-b67b6286c2f4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 213.89, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:7c9dfd94-affe-e19b-7a34-553568d88618", "resource": { "resourceType": "Observation", "id": "7c9dfd94-affe-e19b-7a34-553568d88618", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 171.3, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:eb9b5d4a-8d7f-7e15-6de3-cb81a2d0c229", "resource": { "resourceType": "Observation", "id": "eb9b5d4a-8d7f-7e15-6de3-cb81a2d0c229", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 137.77, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1072e45f-1ce2-98ac-1934-bdfe41133795", "resource": { "resourceType": "Observation", "id": "1072e45f-1ce2-98ac-1934-bdfe41133795", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 41.86, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d240af9a-ac57-db0b-40f2-7673f2eaa28c", "resource": { "resourceType": "Observation", "id": "d240af9a-ac57-db0b-40f2-7673f2eaa28c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 9.57, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:93d75fdb-68f9-dcda-c7a5-016d07a14b08", "resource": { "resourceType": "Observation", "id": "93d75fdb-68f9-dcda-c7a5-016d07a14b08", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 81.97, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:338903bf-5341-5d63-a39a-110a1f84110d", "resource": { "resourceType": "Observation", "id": "338903bf-5341-5d63-a39a-110a1f84110d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6d28689b-613f-f378-0a18-b912c6537931", "resource": { "resourceType": "Observation", "id": "6d28689b-613f-f378-0a18-b912c6537931", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "valueQuantity": { "value": 7.53, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2f1a06b1-c2fb-5794-200c-584f2b1a7d5f", "resource": { "resourceType": "MedicationRequest", "id": "2f1a06b1-c2fb-5794-200c-584f2b1a7d5f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "authoredOn": "2015-04-05T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:4d0afca3-c730-ac40-4864-43150a9b25d7", "resource": { "resourceType": "Claim", "id": "4d0afca3-c730-ac40-4864-43150a9b25d7", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "created": "2015-04-05T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:2f1a06b1-c2fb-5794-200c-584f2b1a7d5f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6957ce24-7159-68b8-f62b-0322b5fd2e78", "resource": { "resourceType": "MedicationRequest", "id": "6957ce24-7159-68b8-f62b-0322b5fd2e78", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "authoredOn": "2015-04-05T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:0893d9ec-d341-c9ce-c531-40ad576b3c41", "resource": { "resourceType": "Claim", "id": "0893d9ec-d341-c9ce-c531-40ad576b3c41", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "created": "2015-04-05T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:6957ce24-7159-68b8-f62b-0322b5fd2e78" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d43dbaf6-371a-ed0d-e555-a8b9660f6715", "resource": { "resourceType": "MedicationRequest", "id": "d43dbaf6-371a-ed0d-e555-a8b9660f6715", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "authoredOn": "2015-04-05T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:d9bc08e4-08f0-fa20-8b34-64a8daa81bbe", "resource": { "resourceType": "Claim", "id": "d9bc08e4-08f0-fa20-8b34-64a8daa81bbe", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "created": "2015-04-05T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:d43dbaf6-371a-ed0d-e555-a8b9660f6715" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" } ] } ], "total": { "value": 443.42, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:84812bbe-ca0f-fe75-e29d-f718a1fa9a33", "resource": { "resourceType": "Immunization", "id": "84812bbe-ca0f-fe75-e29d-f718a1fa9a33", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "occurrenceDateTime": "2015-04-05T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:94ec36e7-a468-5f1d-c4de-91ea02f8941d", "resource": { "resourceType": "DiagnosticReport", "id": "94ec36e7-a468-5f1d-c4de-91ea02f8941d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:2a40fd29-d72e-4dbd-cbf4-23bc282e7410", "display": "Glucose" }, { "reference": "urn:uuid:4f8ef8fa-d6e5-6d92-6766-b15dc2698a2f", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:6fd1a764-ab40-2d47-4e66-b32f1b65c612", "display": "Creatinine" }, { "reference": "urn:uuid:c60fd50e-c782-9f29-9ce8-1f33444b3492", "display": "Calcium" }, { "reference": "urn:uuid:87ccfd9b-bc5c-1200-5210-80f83272772e", "display": "Sodium" }, { "reference": "urn:uuid:6fb2781b-d2cf-3674-06d6-bd2daf92020d", "display": "Potassium" }, { "reference": "urn:uuid:4a3a76c4-64ac-b6ac-c1a2-fa7c9b72b643", "display": "Chloride" }, { "reference": "urn:uuid:60decde1-872d-2437-ebc3-c3936ddd5c53", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:0467ff4a-09ae-04f5-63dc-399ef7c2af97", "resource": { "resourceType": "DiagnosticReport", "id": "0467ff4a-09ae-04f5-63dc-399ef7c2af97", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" }, "effectiveDateTime": "2015-04-05T03:33:36-06:00", "issued": "2015-04-05T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:91f8b60a-5da1-602f-3d4a-b67b6286c2f4", "display": "Total Cholesterol" }, { "reference": "urn:uuid:7c9dfd94-affe-e19b-7a34-553568d88618", "display": "Triglycerides" }, { "reference": "urn:uuid:eb9b5d4a-8d7f-7e15-6de3-cb81a2d0c229", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:1072e45f-1ce2-98ac-1934-bdfe41133795", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:b1a8e0d0-27fb-a70a-f4a3-49e69b09f235", "resource": { "resourceType": "Claim", "id": "b1a8e0d0-27fb-a70a-f4a3-49e69b09f235", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "created": "2015-04-05T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:84812bbe-ca0f-fe75-e29d-f718a1fa9a33" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:98fce715-8675-d739-bd5e-2f79d2ee5848", "resource": { "resourceType": "ExplanationOfBenefit", "id": "98fce715-8675-d739-bd5e-2f79d2ee5848", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "b1a8e0d0-27fb-a70a-f4a3-49e69b09f235" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-04-05T03:48:36-06:00", "end": "2016-04-05T03:48:36-06:00" }, "created": "2015-04-05T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:b1a8e0d0-27fb-a70a-f4a3-49e69b09f235" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:2858ffe8-ea73-7337-f453-c3a8c62a4869" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2015-04-05T03:33:36-06:00", "end": "2015-04-05T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 112.41600000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:fba94d62-55ff-b516-6d2e-6b27df991c5f", "resource": { "resourceType": "Encounter", "id": "fba94d62-55ff-b516-6d2e-6b27df991c5f", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:198b89d4-96cd-6b0f-4d2a-322dbab5730f", "resource": { "resourceType": "Procedure", "id": "198b89d4-96cd-6b0f-4d2a-322dbab5730f", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:fba94d62-55ff-b516-6d2e-6b27df991c5f" }, "performedPeriod": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:44:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:60e357dd-31be-d9d0-3a23-3fca9dd2bef7", "resource": { "resourceType": "Procedure", "id": "60e357dd-31be-d9d0-3a23-3fca9dd2bef7", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:fba94d62-55ff-b516-6d2e-6b27df991c5f" }, "performedPeriod": { "start": "2015-06-07T03:33:36-06:00", "end": "2015-06-07T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:4c8e75ed-3e2f-15e7-d410-ac122ce780fe", "resource": { "resourceType": "Claim", "id": "4c8e75ed-3e2f-15e7-d410-ac122ce780fe", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:48:36-06:00" }, "created": "2015-05-31T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:198b89d4-96cd-6b0f-4d2a-322dbab5730f" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:60e357dd-31be-d9d0-3a23-3fca9dd2bef7" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:fba94d62-55ff-b516-6d2e-6b27df991c5f" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3884.55, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2367.14, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:98560a70-788b-9bab-633e-dc00c7dc88de", "resource": { "resourceType": "ExplanationOfBenefit", "id": "98560a70-788b-9bab-633e-dc00c7dc88de", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "4c8e75ed-3e2f-15e7-d410-ac122ce780fe" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-05-31T03:48:36-06:00", "end": "2016-05-31T03:48:36-06:00" }, "created": "2015-05-31T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:4c8e75ed-3e2f-15e7-d410-ac122ce780fe" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:fba94d62-55ff-b516-6d2e-6b27df991c5f" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3884.55, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 776.9100000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3107.6400000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3884.55, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3884.55, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-05-31T03:33:36-06:00", "end": "2015-05-31T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2367.14, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 473.428, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1893.712, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2367.14, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2367.14, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5001.352000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:3878e3fa-25d0-5d5a-6a05-ded34e7c29e6", "resource": { "resourceType": "Encounter", "id": "3878e3fa-25d0-5d5a-6a05-ded34e7c29e6", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:4c9d08c0-6234-0f81-14f7-cc92159977fb", "resource": { "resourceType": "Procedure", "id": "4c9d08c0-6234-0f81-14f7-cc92159977fb", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3878e3fa-25d0-5d5a-6a05-ded34e7c29e6" }, "performedPeriod": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:47:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7a064949-e822-57a0-f07d-f9ef16ffd0df", "resource": { "resourceType": "Procedure", "id": "7a064949-e822-57a0-f07d-f9ef16ffd0df", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3878e3fa-25d0-5d5a-6a05-ded34e7c29e6" }, "performedPeriod": { "start": "2015-09-06T03:33:36-06:00", "end": "2015-09-06T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:0c96ca66-5e57-c10d-c2f5-155537fb35b5", "resource": { "resourceType": "Claim", "id": "0c96ca66-5e57-c10d-c2f5-155537fb35b5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:48:36-06:00" }, "created": "2015-08-30T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:4c9d08c0-6234-0f81-14f7-cc92159977fb" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:7a064949-e822-57a0-f07d-f9ef16ffd0df" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:3878e3fa-25d0-5d5a-6a05-ded34e7c29e6" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3084.38, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4771.19, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:7cf9ba5e-facd-9c18-c2c5-813b504e38c4", "resource": { "resourceType": "ExplanationOfBenefit", "id": "7cf9ba5e-facd-9c18-c2c5-813b504e38c4", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "0c96ca66-5e57-c10d-c2f5-155537fb35b5" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-08-30T03:48:36-06:00", "end": "2016-08-30T03:48:36-06:00" }, "created": "2015-08-30T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:0c96ca66-5e57-c10d-c2f5-155537fb35b5" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:3878e3fa-25d0-5d5a-6a05-ded34e7c29e6" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3084.38, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 616.8760000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2467.5040000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3084.38, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3084.38, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-08-30T03:33:36-06:00", "end": "2015-08-30T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4771.19, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 954.2379999999999, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3816.9519999999999, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4771.19, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4771.19, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6284.456, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:83a7a56e-f262-2b6f-c9f6-7fb8dd72837b", "resource": { "resourceType": "Encounter", "id": "83a7a56e-f262-2b6f-c9f6-7fb8dd72837b", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:67771d70-950b-c3c4-a990-035dc04d38b4", "resource": { "resourceType": "Procedure", "id": "67771d70-950b-c3c4-a990-035dc04d38b4", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:83a7a56e-f262-2b6f-c9f6-7fb8dd72837b" }, "performedPeriod": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:6263a8d9-d22b-c1ac-7008-39404650b73c", "resource": { "resourceType": "Procedure", "id": "6263a8d9-d22b-c1ac-7008-39404650b73c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:83a7a56e-f262-2b6f-c9f6-7fb8dd72837b" }, "performedPeriod": { "start": "2015-12-06T02:33:36-07:00", "end": "2015-12-06T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:a3602ce9-0a80-79ca-c437-205316998093", "resource": { "resourceType": "Claim", "id": "a3602ce9-0a80-79ca-c437-205316998093", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" }, "created": "2015-11-29T02:49:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:67771d70-950b-c3c4-a990-035dc04d38b4" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:6263a8d9-d22b-c1ac-7008-39404650b73c" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:83a7a56e-f262-2b6f-c9f6-7fb8dd72837b" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 1736.66, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2465.31, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:efa9471c-cb83-872c-631b-c1fe702c47ef", "resource": { "resourceType": "ExplanationOfBenefit", "id": "efa9471c-cb83-872c-631b-c1fe702c47ef", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "a3602ce9-0a80-79ca-c437-205316998093" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2015-11-29T02:49:36-07:00", "end": "2016-11-29T02:49:36-07:00" }, "created": "2015-11-29T02:49:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:a3602ce9-0a80-79ca-c437-205316998093" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:83a7a56e-f262-2b6f-c9f6-7fb8dd72837b" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 1736.66, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 347.33200000000007, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1389.3280000000003, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 1736.66, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 1736.66, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2015-11-29T02:33:36-07:00", "end": "2015-11-29T02:49:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2465.31, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 493.062, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1972.248, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2465.31, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2465.31, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3361.576, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:345f49e7-34f4-1bf4-2f63-dfeac4576d86", "resource": { "resourceType": "Encounter", "id": "345f49e7-34f4-1bf4-2f63-dfeac4576d86", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:7176d0a1-2323-383a-ff60-2b1def9a6a0d", "resource": { "resourceType": "Procedure", "id": "7176d0a1-2323-383a-ff60-2b1def9a6a0d", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:345f49e7-34f4-1bf4-2f63-dfeac4576d86" }, "performedPeriod": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:46:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:748a1ebd-b191-eb31-ae1c-5848b899ee7b", "resource": { "resourceType": "Procedure", "id": "748a1ebd-b191-eb31-ae1c-5848b899ee7b", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:345f49e7-34f4-1bf4-2f63-dfeac4576d86" }, "performedPeriod": { "start": "2016-03-06T02:33:36-07:00", "end": "2016-03-06T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7c04be40-8fd0-0288-b7f3-a55d67cfbc12", "resource": { "resourceType": "Claim", "id": "7c04be40-8fd0-0288-b7f3-a55d67cfbc12", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:48:36-07:00" }, "created": "2016-02-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:7176d0a1-2323-383a-ff60-2b1def9a6a0d" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:748a1ebd-b191-eb31-ae1c-5848b899ee7b" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:345f49e7-34f4-1bf4-2f63-dfeac4576d86" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3192.25, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3092.27, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:64c61172-e88b-cc12-7f6f-a4641811789f", "resource": { "resourceType": "ExplanationOfBenefit", "id": "64c61172-e88b-cc12-7f6f-a4641811789f", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "7c04be40-8fd0-0288-b7f3-a55d67cfbc12" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-02-28T02:48:36-07:00", "end": "2017-02-28T02:48:36-07:00" }, "created": "2016-02-28T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:7c04be40-8fd0-0288-b7f3-a55d67cfbc12" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:345f49e7-34f4-1bf4-2f63-dfeac4576d86" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3192.25, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 638.45, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2553.8, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3192.25, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3192.25, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-02-28T02:33:36-07:00", "end": "2016-02-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3092.27, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 618.4540000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2473.8160000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3092.27, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3092.27, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5027.616, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff", "resource": { "resourceType": "Encounter", "id": "bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:79588641-1045-974e-d83a-2a886af50be5", "resource": { "resourceType": "Condition", "id": "79588641-1045-974e-d83a-2a886af50be5", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "80394007", "display": "Hyperglycemia (disorder)" } ], "text": "Hyperglycemia (disorder)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "onsetDateTime": "2016-04-10T03:33:36-06:00", "recordedDate": "2016-04-10T03:33:36-06:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:0775e28e-a9eb-1394-a1d6-b5141e64f6db", "resource": { "resourceType": "Condition", "id": "0775e28e-a9eb-1394-a1d6-b5141e64f6db", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "15777000", "display": "Prediabetes" } ], "text": "Prediabetes" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "onsetDateTime": "2016-04-10T03:33:36-06:00", "recordedDate": "2016-04-10T03:33:36-06:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:ae4cf216-9f69-fa3e-2dbc-32d568574786", "resource": { "resourceType": "Observation", "id": "ae4cf216-9f69-fa3e-2dbc-32d568574786", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3e24d3b9-919b-4926-58f6-ac69a1bc1f2d", "resource": { "resourceType": "Observation", "id": "3e24d3b9-919b-4926-58f6-ac69a1bc1f2d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 2, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ba9abd17-eb8a-e761-9afc-cdbf7a598e7b", "resource": { "resourceType": "Observation", "id": "ba9abd17-eb8a-e761-9afc-cdbf7a598e7b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3561e2fd-53f5-d6a1-f8fa-c59e48fbbf84", "resource": { "resourceType": "Observation", "id": "3561e2fd-53f5-d6a1-f8fa-c59e48fbbf84", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6c34f51a-042f-96d9-3033-0a8c52ef3c05", "resource": { "resourceType": "Observation", "id": "6c34f51a-042f-96d9-3033-0a8c52ef3c05", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 80, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 105, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d1b720f7-0987-a026-cfe6-18d19ae2d3ef", "resource": { "resourceType": "Observation", "id": "d1b720f7-0987-a026-cfe6-18d19ae2d3ef", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 83, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:926dd028-3472-16ed-e8af-7dd96d22e826", "resource": { "resourceType": "Observation", "id": "926dd028-3472-16ed-e8af-7dd96d22e826", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 16, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:73db95bd-c745-1e40-3757-c4baa5f81d85", "resource": { "resourceType": "Observation", "id": "73db95bd-c745-1e40-3757-c4baa5f81d85", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 148.24, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5f57feff-f78e-6c85-5900-1815230fbc25", "resource": { "resourceType": "Observation", "id": "5f57feff-f78e-6c85-5900-1815230fbc25", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 18.58, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3bc73b5b-0f1b-0659-cf85-ad2202743edf", "resource": { "resourceType": "Observation", "id": "3bc73b5b-0f1b-0659-cf85-ad2202743edf", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 1.45, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d40fcf95-9705-43b1-e448-4c051500d70e", "resource": { "resourceType": "Observation", "id": "d40fcf95-9705-43b1-e448-4c051500d70e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 9.57, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:cb5bc849-05bb-8342-de60-896517a2e899", "resource": { "resourceType": "Observation", "id": "cb5bc849-05bb-8342-de60-896517a2e899", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 138.57, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9f161f8f-1b34-3023-6d07-853efa68c230", "resource": { "resourceType": "Observation", "id": "9f161f8f-1b34-3023-6d07-853efa68c230", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 3.76, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f86c49f9-82a9-fdaf-90bb-42f6568d15d5", "resource": { "resourceType": "Observation", "id": "f86c49f9-82a9-fdaf-90bb-42f6568d15d5", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 102.58, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:cf271ec6-b185-7daf-02c7-eead99a2f59d", "resource": { "resourceType": "Observation", "id": "cf271ec6-b185-7daf-02c7-eead99a2f59d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 25.14, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4d2d8f51-edc7-74b9-fc8f-a3dac3fe58b7", "resource": { "resourceType": "Observation", "id": "4d2d8f51-edc7-74b9-fc8f-a3dac3fe58b7", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 253.16, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e036e1cc-2d99-90d2-036f-89138fb16cad", "resource": { "resourceType": "Observation", "id": "e036e1cc-2d99-90d2-036f-89138fb16cad", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 358.04, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4d59632a-43e1-665a-ccba-552c9c3736ea", "resource": { "resourceType": "Observation", "id": "4d59632a-43e1-665a-ccba-552c9c3736ea", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 155.49, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f37dc45f-d50b-d729-842d-9182c5684a7b", "resource": { "resourceType": "Observation", "id": "f37dc45f-d50b-d729-842d-9182c5684a7b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 26.07, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:358e96cd-8a05-47f4-6fc8-2d9912de9619", "resource": { "resourceType": "Observation", "id": "358e96cd-8a05-47f4-6fc8-2d9912de9619", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 6.32, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:76be9bfa-37b5-47f5-9b3e-37e2ebb98e66", "resource": { "resourceType": "Observation", "id": "76be9bfa-37b5-47f5-9b3e-37e2ebb98e66", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 65.38, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:51b7dc80-6d9a-8ecb-7cae-cfe232043877", "resource": { "resourceType": "Observation", "id": "51b7dc80-6d9a-8ecb-7cae-cfe232043877", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1a30ba46-708e-749e-50fe-a5701d12d892", "resource": { "resourceType": "Observation", "id": "1a30ba46-708e-749e-50fe-a5701d12d892", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:168371f2-cd85-4886-c18a-995ba3464938", "resource": { "resourceType": "MedicationRequest", "id": "168371f2-cd85-4886-c18a-995ba3464938", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "authoredOn": "2016-04-10T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b7b7bfa0-cd93-292d-940b-5338cdff3e65", "resource": { "resourceType": "Claim", "id": "b7b7bfa0-cd93-292d-940b-5338cdff3e65", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "created": "2016-04-10T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:168371f2-cd85-4886-c18a-995ba3464938" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e1359ad0-6ed3-43b2-19bb-e072be6bf915", "resource": { "resourceType": "MedicationRequest", "id": "e1359ad0-6ed3-43b2-19bb-e072be6bf915", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "authoredOn": "2016-04-10T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b9533d9d-8749-9cd0-8962-b0a18b7f2f0a", "resource": { "resourceType": "Claim", "id": "b9533d9d-8749-9cd0-8962-b0a18b7f2f0a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "created": "2016-04-10T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:e1359ad0-6ed3-43b2-19bb-e072be6bf915" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" } ] } ], "total": { "value": 308.1, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:a05feb34-2db5-c83f-b9fd-832191072acc", "resource": { "resourceType": "MedicationRequest", "id": "a05feb34-2db5-c83f-b9fd-832191072acc", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "authoredOn": "2016-04-10T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:9ff02982-e2cf-3259-f6c6-19e2a1c867f1", "resource": { "resourceType": "Claim", "id": "9ff02982-e2cf-3259-f6c6-19e2a1c867f1", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "created": "2016-04-10T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:a05feb34-2db5-c83f-b9fd-832191072acc" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:af47622f-91c9-e001-1a4e-c57cb2ef2f9e", "resource": { "resourceType": "Immunization", "id": "af47622f-91c9-e001-1a4e-c57cb2ef2f9e", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "occurrenceDateTime": "2016-04-10T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:87061ecb-d38c-c8c0-52d3-1e85aa5ff94d", "resource": { "resourceType": "DiagnosticReport", "id": "87061ecb-d38c-c8c0-52d3-1e85aa5ff94d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:73db95bd-c745-1e40-3757-c4baa5f81d85", "display": "Glucose" }, { "reference": "urn:uuid:5f57feff-f78e-6c85-5900-1815230fbc25", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:3bc73b5b-0f1b-0659-cf85-ad2202743edf", "display": "Creatinine" }, { "reference": "urn:uuid:d40fcf95-9705-43b1-e448-4c051500d70e", "display": "Calcium" }, { "reference": "urn:uuid:cb5bc849-05bb-8342-de60-896517a2e899", "display": "Sodium" }, { "reference": "urn:uuid:9f161f8f-1b34-3023-6d07-853efa68c230", "display": "Potassium" }, { "reference": "urn:uuid:f86c49f9-82a9-fdaf-90bb-42f6568d15d5", "display": "Chloride" }, { "reference": "urn:uuid:cf271ec6-b185-7daf-02c7-eead99a2f59d", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:dd035447-caf1-2f30-06ca-8026a3a693d0", "resource": { "resourceType": "DiagnosticReport", "id": "dd035447-caf1-2f30-06ca-8026a3a693d0", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" }, "effectiveDateTime": "2016-04-10T03:33:36-06:00", "issued": "2016-04-10T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:4d2d8f51-edc7-74b9-fc8f-a3dac3fe58b7", "display": "Total Cholesterol" }, { "reference": "urn:uuid:e036e1cc-2d99-90d2-036f-89138fb16cad", "display": "Triglycerides" }, { "reference": "urn:uuid:4d59632a-43e1-665a-ccba-552c9c3736ea", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:f37dc45f-d50b-d729-842d-9182c5684a7b", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:e4aa71a6-f3f4-9b9d-3b8f-17ed2cc05a95", "resource": { "resourceType": "Claim", "id": "e4aa71a6-f3f4-9b9d-3b8f-17ed2cc05a95", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "created": "2016-04-10T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:af47622f-91c9-e001-1a4e-c57cb2ef2f9e" } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:79588641-1045-974e-d83a-2a886af50be5" } }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:0775e28e-a9eb-1394-a1d6-b5141e64f6db" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 3, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "80394007", "display": "Hyperglycemia (disorder)" } ], "text": "Hyperglycemia (disorder)" } }, { "sequence": 4, "diagnosisSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "15777000", "display": "Prediabetes" } ], "text": "Prediabetes" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ef9f25f4-c23d-5ce8-a9c5-9edc1cfdfb2a", "resource": { "resourceType": "ExplanationOfBenefit", "id": "ef9f25f4-c23d-5ce8-a9c5-9edc1cfdfb2a", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "e4aa71a6-f3f4-9b9d-3b8f-17ed2cc05a95" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-04-10T03:48:36-06:00", "end": "2017-04-10T03:48:36-06:00" }, "created": "2016-04-10T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:e4aa71a6-f3f4-9b9d-3b8f-17ed2cc05a95" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:79588641-1045-974e-d83a-2a886af50be5" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:0775e28e-a9eb-1394-a1d6-b5141e64f6db" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:bceecbcf-16a9-cda8-f5c8-5f8d2ffa02ff" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "80394007", "display": "Hyperglycemia (disorder)" } ], "text": "Hyperglycemia (disorder)" }, "servicedPeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } }, { "sequence": 4, "diagnosisSequence": [ 2 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "15777000", "display": "Prediabetes" } ], "text": "Prediabetes" }, "servicedPeriod": { "start": "2016-04-10T03:33:36-06:00", "end": "2016-04-10T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] } } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 112.41600000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:51031177-76eb-b3ae-b15f-0fc8f0fd8f03", "resource": { "resourceType": "Encounter", "id": "51031177-76eb-b3ae-b15f-0fc8f0fd8f03", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:f2c8d623-18b0-0baa-92ce-eee93f860d7b", "resource": { "resourceType": "Procedure", "id": "f2c8d623-18b0-0baa-92ce-eee93f860d7b", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:51031177-76eb-b3ae-b15f-0fc8f0fd8f03" }, "performedPeriod": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:45:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:d3433b51-85c0-e757-79a5-f6a460195a18", "resource": { "resourceType": "Procedure", "id": "d3433b51-85c0-e757-79a5-f6a460195a18", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:51031177-76eb-b3ae-b15f-0fc8f0fd8f03" }, "performedPeriod": { "start": "2016-06-05T03:33:36-06:00", "end": "2016-06-05T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:48d658b2-a3d1-61d9-d76a-3daebda27312", "resource": { "resourceType": "Claim", "id": "48d658b2-a3d1-61d9-d76a-3daebda27312", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:48:36-06:00" }, "created": "2016-05-29T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:f2c8d623-18b0-0baa-92ce-eee93f860d7b" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:d3433b51-85c0-e757-79a5-f6a460195a18" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:51031177-76eb-b3ae-b15f-0fc8f0fd8f03" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4145.21, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 1473.89, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:0d9bfc83-58d3-6b1d-7983-2a5951f98416", "resource": { "resourceType": "ExplanationOfBenefit", "id": "0d9bfc83-58d3-6b1d-7983-2a5951f98416", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "48d658b2-a3d1-61d9-d76a-3daebda27312" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-05-29T03:48:36-06:00", "end": "2017-05-29T03:48:36-06:00" }, "created": "2016-05-29T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:48d658b2-a3d1-61d9-d76a-3daebda27312" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:51031177-76eb-b3ae-b15f-0fc8f0fd8f03" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4145.21, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 829.042, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3316.168, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4145.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4145.21, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-05-29T03:33:36-06:00", "end": "2016-05-29T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 1473.89, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 294.778, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1179.112, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 1473.89, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 1473.89, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4495.280000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:c42bc0fa-365f-223e-6ba0-c724324fe147", "resource": { "resourceType": "Encounter", "id": "c42bc0fa-365f-223e-6ba0-c724324fe147", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:a4ca8508-3b4a-f22a-ae6b-4c95f5322e84", "resource": { "resourceType": "Procedure", "id": "a4ca8508-3b4a-f22a-ae6b-4c95f5322e84", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c42bc0fa-365f-223e-6ba0-c724324fe147" }, "performedPeriod": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:44:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:064c3c41-4996-5485-b9c0-f450a0ef36f0", "resource": { "resourceType": "Procedure", "id": "064c3c41-4996-5485-b9c0-f450a0ef36f0", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c42bc0fa-365f-223e-6ba0-c724324fe147" }, "performedPeriod": { "start": "2016-09-04T03:33:36-06:00", "end": "2016-09-04T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:6b2e4a13-9483-5ecd-a795-6961111638ae", "resource": { "resourceType": "Claim", "id": "6b2e4a13-9483-5ecd-a795-6961111638ae", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:48:36-06:00" }, "created": "2016-08-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:a4ca8508-3b4a-f22a-ae6b-4c95f5322e84" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:064c3c41-4996-5485-b9c0-f450a0ef36f0" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:c42bc0fa-365f-223e-6ba0-c724324fe147" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4872.75, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2912.79, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:011fdc43-69d9-7dbe-51e7-69d4b3a7a8ec", "resource": { "resourceType": "ExplanationOfBenefit", "id": "011fdc43-69d9-7dbe-51e7-69d4b3a7a8ec", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "6b2e4a13-9483-5ecd-a795-6961111638ae" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-08-28T03:48:36-06:00", "end": "2017-08-28T03:48:36-06:00" }, "created": "2016-08-28T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:6b2e4a13-9483-5ecd-a795-6961111638ae" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:c42bc0fa-365f-223e-6ba0-c724324fe147" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4872.75, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 974.5500000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3898.2000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4872.75, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4872.75, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-08-28T03:33:36-06:00", "end": "2016-08-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2912.79, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 582.558, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2330.232, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2912.79, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2912.79, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6228.432000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:2a90f88e-040e-02f7-0876-6d8fbebfb423", "resource": { "resourceType": "Encounter", "id": "2a90f88e-040e-02f7-0876-6d8fbebfb423", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:be3831b1-1fb5-68dc-432b-665fae31fe9c", "resource": { "resourceType": "Procedure", "id": "be3831b1-1fb5-68dc-432b-665fae31fe9c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2a90f88e-040e-02f7-0876-6d8fbebfb423" }, "performedPeriod": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:630a3790-976a-70be-a9c4-ed4eda026935", "resource": { "resourceType": "Procedure", "id": "630a3790-976a-70be-a9c4-ed4eda026935", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:2a90f88e-040e-02f7-0876-6d8fbebfb423" }, "performedPeriod": { "start": "2016-12-04T02:33:36-07:00", "end": "2016-12-04T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:7f1db6b1-6c86-7f39-5188-7139331ede64", "resource": { "resourceType": "Claim", "id": "7f1db6b1-6c86-7f39-5188-7139331ede64", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" }, "created": "2016-11-27T02:50:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:be3831b1-1fb5-68dc-432b-665fae31fe9c" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:630a3790-976a-70be-a9c4-ed4eda026935" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:2a90f88e-040e-02f7-0876-6d8fbebfb423" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2702.4, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2132.63, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f8a93aea-22d8-dadd-63bf-3a9dd77a6b7c", "resource": { "resourceType": "ExplanationOfBenefit", "id": "f8a93aea-22d8-dadd-63bf-3a9dd77a6b7c", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "7f1db6b1-6c86-7f39-5188-7139331ede64" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2016-11-27T02:50:36-07:00", "end": "2017-11-27T02:50:36-07:00" }, "created": "2016-11-27T02:50:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:7f1db6b1-6c86-7f39-5188-7139331ede64" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:2a90f88e-040e-02f7-0876-6d8fbebfb423" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2702.4, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 540.48, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2161.92, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2702.4, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2702.4, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2016-11-27T02:33:36-07:00", "end": "2016-11-27T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2132.63, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 426.52600000000009, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1706.1040000000003, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2132.63, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2132.63, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3868.0240000000005, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:e0f0095a-d840-b110-c4df-58b8e9ea2a2f", "resource": { "resourceType": "Encounter", "id": "e0f0095a-d840-b110-c4df-58b8e9ea2a2f", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:94ce259c-d0e8-0532-69ad-cbd16128be53", "resource": { "resourceType": "Procedure", "id": "94ce259c-d0e8-0532-69ad-cbd16128be53", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e0f0095a-d840-b110-c4df-58b8e9ea2a2f" }, "performedPeriod": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:ece2f63b-7c1b-ee02-fea8-80cdcc6d6be9", "resource": { "resourceType": "Procedure", "id": "ece2f63b-7c1b-ee02-fea8-80cdcc6d6be9", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e0f0095a-d840-b110-c4df-58b8e9ea2a2f" }, "performedPeriod": { "start": "2017-03-05T02:33:36-07:00", "end": "2017-03-05T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:735d3c61-0ea0-c540-63db-f20e1750095a", "resource": { "resourceType": "Claim", "id": "735d3c61-0ea0-c540-63db-f20e1750095a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" }, "created": "2017-02-26T02:50:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:94ce259c-d0e8-0532-69ad-cbd16128be53" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:ece2f63b-7c1b-ee02-fea8-80cdcc6d6be9" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:e0f0095a-d840-b110-c4df-58b8e9ea2a2f" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3506.39, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2945.23, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e66252d2-6c27-2d92-5d31-817962835202", "resource": { "resourceType": "ExplanationOfBenefit", "id": "e66252d2-6c27-2d92-5d31-817962835202", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "735d3c61-0ea0-c540-63db-f20e1750095a" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-02-26T02:50:36-07:00", "end": "2018-02-26T02:50:36-07:00" }, "created": "2017-02-26T02:50:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:735d3c61-0ea0-c540-63db-f20e1750095a" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:e0f0095a-d840-b110-c4df-58b8e9ea2a2f" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3506.39, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 701.278, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2805.112, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3506.39, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3506.39, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-02-26T02:33:36-07:00", "end": "2017-02-26T02:50:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2945.23, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 589.046, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2356.184, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2945.23, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2945.23, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5161.296, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2", "resource": { "resourceType": "Encounter", "id": "6f35e81f-1471-12ab-2280-dfd217835cf2", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:36e6a815-6004-07a9-3480-15507aee3bf1", "resource": { "resourceType": "Observation", "id": "36e6a815-6004-07a9-3480-15507aee3bf1", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:64978877-6e38-a7be-d952-ff6d781906c4", "resource": { "resourceType": "Observation", "id": "64978877-6e38-a7be-d952-ff6d781906c4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 3, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:0ec4aceb-814c-dd12-ce34-57fc00d3d6af", "resource": { "resourceType": "Observation", "id": "0ec4aceb-814c-dd12-ce34-57fc00d3d6af", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6b5e163a-0f19-31e8-50bf-9980ba73763b", "resource": { "resourceType": "Observation", "id": "6b5e163a-0f19-31e8-50bf-9980ba73763b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:318190b3-d467-8fff-7304-54bc655fc938", "resource": { "resourceType": "Observation", "id": "318190b3-d467-8fff-7304-54bc655fc938", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 70, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 102, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:fe4095f0-afec-123a-5f00-cb8752d23105", "resource": { "resourceType": "Observation", "id": "fe4095f0-afec-123a-5f00-cb8752d23105", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 85, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:eb7615bd-c6c6-cc82-79aa-e4e0b55f710e", "resource": { "resourceType": "Observation", "id": "eb7615bd-c6c6-cc82-79aa-e4e0b55f710e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:df7b5a55-717f-adeb-488b-ce48c89cd796", "resource": { "resourceType": "Observation", "id": "df7b5a55-717f-adeb-488b-ce48c89cd796", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 92.86, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5dca7bce-0bdb-e115-3863-de4fdae8aeb6", "resource": { "resourceType": "Observation", "id": "5dca7bce-0bdb-e115-3863-de4fdae8aeb6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 7.95, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6e9016d4-fdfe-4ed4-5c91-8c689e5a39a4", "resource": { "resourceType": "Observation", "id": "6e9016d4-fdfe-4ed4-5c91-8c689e5a39a4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 1.1, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:25153a9c-183b-2713-7f4f-9202bb5dc238", "resource": { "resourceType": "Observation", "id": "25153a9c-183b-2713-7f4f-9202bb5dc238", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 9.29, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2e05c212-af20-93f5-3f8b-88d924c57aac", "resource": { "resourceType": "Observation", "id": "2e05c212-af20-93f5-3f8b-88d924c57aac", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 136.5, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:de268c56-38b4-fb3c-f357-9a87da6037a3", "resource": { "resourceType": "Observation", "id": "de268c56-38b4-fb3c-f357-9a87da6037a3", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 4.34, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6b524866-910d-71ee-db0f-156098b3466c", "resource": { "resourceType": "Observation", "id": "6b524866-910d-71ee-db0f-156098b3466c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 108.5, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:33cac81c-7965-4635-3a6e-fa7fea84e387", "resource": { "resourceType": "Observation", "id": "33cac81c-7965-4635-3a6e-fa7fea84e387", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 27.41, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:56580e5a-7409-c387-d760-d91d6fb91567", "resource": { "resourceType": "Observation", "id": "56580e5a-7409-c387-d760-d91d6fb91567", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 183.74, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ef8d8c83-4efb-9506-6b47-8b213cdaef79", "resource": { "resourceType": "Observation", "id": "ef8d8c83-4efb-9506-6b47-8b213cdaef79", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 146.26, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5921432b-a159-6a28-d882-a6fb83c88164", "resource": { "resourceType": "Observation", "id": "5921432b-a159-6a28-d882-a6fb83c88164", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 94.45, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:fec7ba13-3abd-c19a-9bd6-bab55097f692", "resource": { "resourceType": "Observation", "id": "fec7ba13-3abd-c19a-9bd6-bab55097f692", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 60.04, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2bc30350-31f3-fe61-75b5-a441e230a9ef", "resource": { "resourceType": "Observation", "id": "2bc30350-31f3-fe61-75b5-a441e230a9ef", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 6.59, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:7c823dc9-7007-2b42-bb43-9b18dc7b31f0", "resource": { "resourceType": "Observation", "id": "7c823dc9-7007-2b42-bb43-9b18dc7b31f0", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6690-2", "display": "Leukocytes [#/volume] in Blood by Automated count" } ], "text": "Leukocytes [#/volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 5.618, "unit": "10*3/uL", "system": "http://unitsofmeasure.org", "code": "10*3/uL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f3924aeb-77ef-1064-07aa-bf065eb7a8d7", "resource": { "resourceType": "Observation", "id": "f3924aeb-77ef-1064-07aa-bf065eb7a8d7", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "789-8", "display": "Erythrocytes [#/volume] in Blood by Automated count" } ], "text": "Erythrocytes [#/volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 5.344, "unit": "10*6/uL", "system": "http://unitsofmeasure.org", "code": "10*6/uL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:97f7ab95-d846-7f33-1d18-403e8bb9b534", "resource": { "resourceType": "Observation", "id": "97f7ab95-d846-7f33-1d18-403e8bb9b534", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "718-7", "display": "Hemoglobin [Mass/volume] in Blood" } ], "text": "Hemoglobin [Mass/volume] in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 16.267, "unit": "g/dL", "system": "http://unitsofmeasure.org", "code": "g/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b814b858-65bf-f886-f6db-74b4afbe16ae", "resource": { "resourceType": "Observation", "id": "b814b858-65bf-f886-f6db-74b4afbe16ae", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4544-3", "display": "Hematocrit [Volume Fraction] of Blood by Automated count" } ], "text": "Hematocrit [Volume Fraction] of Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 41.354, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9ebea8dc-b0bc-1103-3cd0-6eac5085bb03", "resource": { "resourceType": "Observation", "id": "9ebea8dc-b0bc-1103-3cd0-6eac5085bb03", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "787-2", "display": "MCV [Entitic volume] by Automated count" } ], "text": "MCV [Entitic volume] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 93.971, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9b571ea6-60b7-37c2-28c4-e88cc49e9f4c", "resource": { "resourceType": "Observation", "id": "9b571ea6-60b7-37c2-28c4-e88cc49e9f4c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "785-6", "display": "MCH [Entitic mass] by Automated count" } ], "text": "MCH [Entitic mass] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 30.893, "unit": "pg", "system": "http://unitsofmeasure.org", "code": "pg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:88e726f9-637a-c330-4a1f-99fa9e830185", "resource": { "resourceType": "Observation", "id": "88e726f9-637a-c330-4a1f-99fa9e830185", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "786-4", "display": "MCHC [Mass/volume] by Automated count" } ], "text": "MCHC [Mass/volume] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 33.584, "unit": "g/dL", "system": "http://unitsofmeasure.org", "code": "g/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8e93e818-7657-6835-87ff-4a233bbba64d", "resource": { "resourceType": "Observation", "id": "8e93e818-7657-6835-87ff-4a233bbba64d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "21000-5", "display": "Erythrocyte distribution width [Entitic volume] by Automated count" } ], "text": "Erythrocyte distribution width [Entitic volume] by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 41.49, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:24946db5-2b6d-7f99-ff88-335817ba36e9", "resource": { "resourceType": "Observation", "id": "24946db5-2b6d-7f99-ff88-335817ba36e9", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "777-3", "display": "Platelets [#/volume] in Blood by Automated count" } ], "text": "Platelets [#/volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 256.55, "unit": "10*3/uL", "system": "http://unitsofmeasure.org", "code": "10*3/uL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:af5348a4-7e69-bda3-686b-8bde59ecfb8e", "resource": { "resourceType": "Observation", "id": "af5348a4-7e69-bda3-686b-8bde59ecfb8e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "32207-3", "display": "Platelet distribution width [Entitic volume] in Blood by Automated count" } ], "text": "Platelet distribution width [Entitic volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 358.41, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:65ddf5d1-8963-4002-1e1e-480536dd75df", "resource": { "resourceType": "Observation", "id": "65ddf5d1-8963-4002-1e1e-480536dd75df", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "32623-1", "display": "Platelet mean volume [Entitic volume] in Blood by Automated count" } ], "text": "Platelet mean volume [Entitic volume] in Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 10.442, "unit": "fL", "system": "http://unitsofmeasure.org", "code": "fL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:146f4075-4df2-15f1-b5f1-6978a93f9fb4", "resource": { "resourceType": "Observation", "id": "146f4075-4df2-15f1-b5f1-6978a93f9fb4", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 85.31, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6f011383-8e63-a695-aa8f-6fd849efd21c", "resource": { "resourceType": "Observation", "id": "6f011383-8e63-a695-aa8f-6fd849efd21c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:95a56e69-c164-99a9-7187-be85713998a5", "resource": { "resourceType": "Observation", "id": "95a56e69-c164-99a9-7187-be85713998a5", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9c2d70f4-85ce-265c-b0ca-0bbaa0a1f4da", "resource": { "resourceType": "MedicationRequest", "id": "9c2d70f4-85ce-265c-b0ca-0bbaa0a1f4da", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "authoredOn": "2017-04-16T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:03a0b294-0ebe-ec79-fd81-2ce38f13d60c", "resource": { "resourceType": "Claim", "id": "03a0b294-0ebe-ec79-fd81-2ce38f13d60c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "created": "2017-04-16T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:9c2d70f4-85ce-265c-b0ca-0bbaa0a1f4da" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:3d7658c0-9805-bbc8-e4dd-d42b29f5c955", "resource": { "resourceType": "MedicationRequest", "id": "3d7658c0-9805-bbc8-e4dd-d42b29f5c955", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "authoredOn": "2017-04-16T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:59a4a0bb-8266-edb4-1f57-134fd09c25d9", "resource": { "resourceType": "Claim", "id": "59a4a0bb-8266-edb4-1f57-134fd09c25d9", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "created": "2017-04-16T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:3d7658c0-9805-bbc8-e4dd-d42b29f5c955" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" } ] } ], "total": { "value": 252.15, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b0b2d078-94ab-352d-f0ef-b7b9dcfb394f", "resource": { "resourceType": "MedicationRequest", "id": "b0b2d078-94ab-352d-f0ef-b7b9dcfb394f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "authoredOn": "2017-04-16T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:ad44c2d9-83f1-08cf-6a6c-d3d1d8b138bf", "resource": { "resourceType": "Claim", "id": "ad44c2d9-83f1-08cf-6a6c-d3d1d8b138bf", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "created": "2017-04-16T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:b0b2d078-94ab-352d-f0ef-b7b9dcfb394f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:3c568320-31a8-0b43-a15b-098e30b7f98c", "resource": { "resourceType": "Immunization", "id": "3c568320-31a8-0b43-a15b-098e30b7f98c", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "occurrenceDateTime": "2017-04-16T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:03d1ab9e-8230-15e5-fc85-6a4ac08ab6b5", "resource": { "resourceType": "DiagnosticReport", "id": "03d1ab9e-8230-15e5-fc85-6a4ac08ab6b5", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:df7b5a55-717f-adeb-488b-ce48c89cd796", "display": "Glucose" }, { "reference": "urn:uuid:5dca7bce-0bdb-e115-3863-de4fdae8aeb6", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:6e9016d4-fdfe-4ed4-5c91-8c689e5a39a4", "display": "Creatinine" }, { "reference": "urn:uuid:25153a9c-183b-2713-7f4f-9202bb5dc238", "display": "Calcium" }, { "reference": "urn:uuid:2e05c212-af20-93f5-3f8b-88d924c57aac", "display": "Sodium" }, { "reference": "urn:uuid:de268c56-38b4-fb3c-f357-9a87da6037a3", "display": "Potassium" }, { "reference": "urn:uuid:6b524866-910d-71ee-db0f-156098b3466c", "display": "Chloride" }, { "reference": "urn:uuid:33cac81c-7965-4635-3a6e-fa7fea84e387", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:638d7bb0-b28b-c9a7-6959-ffde978c6657", "resource": { "resourceType": "DiagnosticReport", "id": "638d7bb0-b28b-c9a7-6959-ffde978c6657", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:56580e5a-7409-c387-d760-d91d6fb91567", "display": "Total Cholesterol" }, { "reference": "urn:uuid:ef8d8c83-4efb-9506-6b47-8b213cdaef79", "display": "Triglycerides" }, { "reference": "urn:uuid:5921432b-a159-6a28-d882-a6fb83c88164", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:fec7ba13-3abd-c19a-9bd6-bab55097f692", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:c065d8ec-3030-ca34-11e5-52ee1d3f6376", "resource": { "resourceType": "DiagnosticReport", "id": "c065d8ec-3030-ca34-11e5-52ee1d3f6376", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "58410-2", "display": "Complete blood count (hemogram) panel - Blood by Automated count" } ], "text": "Complete blood count (hemogram) panel - Blood by Automated count" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" }, "effectiveDateTime": "2017-04-16T03:33:36-06:00", "issued": "2017-04-16T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:7c823dc9-7007-2b42-bb43-9b18dc7b31f0", "display": "Leukocytes [#/volume] in Blood by Automated count" }, { "reference": "urn:uuid:f3924aeb-77ef-1064-07aa-bf065eb7a8d7", "display": "Erythrocytes [#/volume] in Blood by Automated count" }, { "reference": "urn:uuid:97f7ab95-d846-7f33-1d18-403e8bb9b534", "display": "Hemoglobin [Mass/volume] in Blood" }, { "reference": "urn:uuid:b814b858-65bf-f886-f6db-74b4afbe16ae", "display": "Hematocrit [Volume Fraction] of Blood by Automated count" }, { "reference": "urn:uuid:9ebea8dc-b0bc-1103-3cd0-6eac5085bb03", "display": "MCV [Entitic volume] by Automated count" }, { "reference": "urn:uuid:9b571ea6-60b7-37c2-28c4-e88cc49e9f4c", "display": "MCH [Entitic mass] by Automated count" }, { "reference": "urn:uuid:88e726f9-637a-c330-4a1f-99fa9e830185", "display": "MCHC [Mass/volume] by Automated count" }, { "reference": "urn:uuid:8e93e818-7657-6835-87ff-4a233bbba64d", "display": "Erythrocyte distribution width [Entitic volume] by Automated count" }, { "reference": "urn:uuid:24946db5-2b6d-7f99-ff88-335817ba36e9", "display": "Platelets [#/volume] in Blood by Automated count" }, { "reference": "urn:uuid:af5348a4-7e69-bda3-686b-8bde59ecfb8e", "display": "Platelet distribution width [Entitic volume] in Blood by Automated count" }, { "reference": "urn:uuid:65ddf5d1-8963-4002-1e1e-480536dd75df", "display": "Platelet mean volume [Entitic volume] in Blood by Automated count" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:6b24af97-19fe-0758-ebcf-827c6aa76ffc", "resource": { "resourceType": "Claim", "id": "6b24af97-19fe-0758-ebcf-827c6aa76ffc", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "created": "2017-04-16T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:3c568320-31a8-0b43-a15b-098e30b7f98c" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:10bc6659-4f02-b89e-fc5a-c0c3cd3b5301", "resource": { "resourceType": "ExplanationOfBenefit", "id": "10bc6659-4f02-b89e-fc5a-c0c3cd3b5301", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "6b24af97-19fe-0758-ebcf-827c6aa76ffc" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-04-16T03:48:36-06:00", "end": "2018-04-16T03:48:36-06:00" }, "created": "2017-04-16T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:6b24af97-19fe-0758-ebcf-827c6aa76ffc" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:6f35e81f-1471-12ab-2280-dfd217835cf2" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2017-04-16T03:33:36-06:00", "end": "2017-04-16T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 112.41600000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:6e095932-bd46-ef3a-4d0c-4946f25b974c", "resource": { "resourceType": "Encounter", "id": "6e095932-bd46-ef3a-4d0c-4946f25b974c", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:9a3b8faf-1a70-e229-75a6-2426f5982e19", "resource": { "resourceType": "Procedure", "id": "9a3b8faf-1a70-e229-75a6-2426f5982e19", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6e095932-bd46-ef3a-4d0c-4946f25b974c" }, "performedPeriod": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:43:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:af692259-5030-5896-13a9-4ab44066fa1c", "resource": { "resourceType": "Procedure", "id": "af692259-5030-5896-13a9-4ab44066fa1c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:6e095932-bd46-ef3a-4d0c-4946f25b974c" }, "performedPeriod": { "start": "2017-06-04T03:33:36-06:00", "end": "2017-06-04T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:abdd036e-510b-d67f-1afd-0146e38986c5", "resource": { "resourceType": "Claim", "id": "abdd036e-510b-d67f-1afd-0146e38986c5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:48:36-06:00" }, "created": "2017-05-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:9a3b8faf-1a70-e229-75a6-2426f5982e19" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:af692259-5030-5896-13a9-4ab44066fa1c" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:6e095932-bd46-ef3a-4d0c-4946f25b974c" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3525.97, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3783.45, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:cfbd1ed3-45c1-6f98-47d1-7a4e61806fc5", "resource": { "resourceType": "ExplanationOfBenefit", "id": "cfbd1ed3-45c1-6f98-47d1-7a4e61806fc5", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "abdd036e-510b-d67f-1afd-0146e38986c5" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-05-28T03:48:36-06:00", "end": "2018-05-28T03:48:36-06:00" }, "created": "2017-05-28T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:abdd036e-510b-d67f-1afd-0146e38986c5" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:6e095932-bd46-ef3a-4d0c-4946f25b974c" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3525.97, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 705.194, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2820.776, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3525.97, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3525.97, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-05-28T03:33:36-06:00", "end": "2017-05-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3783.45, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 756.69, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3026.76, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3783.45, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3783.45, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5847.536, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:64de0547-ba27-646f-1ca1-16a81a4f3cd1", "resource": { "resourceType": "Encounter", "id": "64de0547-ba27-646f-1ca1-16a81a4f3cd1", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:294996dc-b096-edd0-5194-d73303bbb5a6", "resource": { "resourceType": "Procedure", "id": "294996dc-b096-edd0-5194-d73303bbb5a6", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:64de0547-ba27-646f-1ca1-16a81a4f3cd1" }, "performedPeriod": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:936160a3-fead-da6a-d1c5-d3a1b25ff24c", "resource": { "resourceType": "Procedure", "id": "936160a3-fead-da6a-d1c5-d3a1b25ff24c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:64de0547-ba27-646f-1ca1-16a81a4f3cd1" }, "performedPeriod": { "start": "2017-09-03T03:33:36-06:00", "end": "2017-09-03T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:dfdca1a6-a3d9-e2b2-d01e-ca930f96ab9e", "resource": { "resourceType": "Claim", "id": "dfdca1a6-a3d9-e2b2-d01e-ca930f96ab9e", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" }, "created": "2017-08-27T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:294996dc-b096-edd0-5194-d73303bbb5a6" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:936160a3-fead-da6a-d1c5-d3a1b25ff24c" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:64de0547-ba27-646f-1ca1-16a81a4f3cd1" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2912.01, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3238.28, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:896d2b1b-a3ea-d706-ee3e-1ee052bd9008", "resource": { "resourceType": "ExplanationOfBenefit", "id": "896d2b1b-a3ea-d706-ee3e-1ee052bd9008", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "dfdca1a6-a3d9-e2b2-d01e-ca930f96ab9e" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-08-27T03:48:36-06:00", "end": "2018-08-27T03:48:36-06:00" }, "created": "2017-08-27T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:dfdca1a6-a3d9-e2b2-d01e-ca930f96ab9e" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:64de0547-ba27-646f-1ca1-16a81a4f3cd1" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2912.01, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 582.402, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2329.608, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2912.01, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2912.01, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-08-27T03:33:36-06:00", "end": "2017-08-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3238.28, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 647.6560000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2590.6240000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3238.28, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3238.28, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4920.232, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:1ed58fd7-7417-0c16-44e9-d633d9c1a092", "resource": { "resourceType": "Encounter", "id": "1ed58fd7-7417-0c16-44e9-d633d9c1a092", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:c9ee56fe-f9af-a97f-8cac-6ce179a5da1e", "resource": { "resourceType": "Procedure", "id": "c9ee56fe-f9af-a97f-8cac-6ce179a5da1e", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:1ed58fd7-7417-0c16-44e9-d633d9c1a092" }, "performedPeriod": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:44:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:97bf2604-1d78-beb8-f74a-92f083f4aeed", "resource": { "resourceType": "Procedure", "id": "97bf2604-1d78-beb8-f74a-92f083f4aeed", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:1ed58fd7-7417-0c16-44e9-d633d9c1a092" }, "performedPeriod": { "start": "2017-12-03T02:33:36-07:00", "end": "2017-12-03T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:3aac15cf-d773-4231-1d2f-267a7e111467", "resource": { "resourceType": "Claim", "id": "3aac15cf-d773-4231-1d2f-267a7e111467", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:48:36-07:00" }, "created": "2017-11-26T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:c9ee56fe-f9af-a97f-8cac-6ce179a5da1e" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:97bf2604-1d78-beb8-f74a-92f083f4aeed" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:1ed58fd7-7417-0c16-44e9-d633d9c1a092" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4472.4, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3549.34, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9306a73b-8325-5eb9-e5eb-ff35db64291b", "resource": { "resourceType": "ExplanationOfBenefit", "id": "9306a73b-8325-5eb9-e5eb-ff35db64291b", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "3aac15cf-d773-4231-1d2f-267a7e111467" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2017-11-26T02:48:36-07:00", "end": "2018-11-26T02:48:36-07:00" }, "created": "2017-11-26T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:3aac15cf-d773-4231-1d2f-267a7e111467" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:1ed58fd7-7417-0c16-44e9-d633d9c1a092" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4472.4, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 894.48, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3577.92, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4472.4, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4472.4, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2017-11-26T02:33:36-07:00", "end": "2017-11-26T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3549.34, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 709.868, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2839.472, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3549.34, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3549.34, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 6417.392, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:7b550ac5-164f-b31f-8dc3-5f51afb0b703", "resource": { "resourceType": "Encounter", "id": "7b550ac5-164f-b31f-8dc3-5f51afb0b703", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "185345009", "display": "Encounter for symptom" } ], "text": "Encounter for symptom" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-01-28T02:33:36-07:00", "end": "2018-01-28T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } } ], "period": { "start": "2018-01-28T02:33:36-07:00", "end": "2018-01-28T02:48:36-07:00" }, "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "195662009", "display": "Acute viral pharyngitis (disorder)" } ] } ], "serviceProvider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:cb99af7e-31c4-681c-f517-1d8583a6160d", "resource": { "resourceType": "Condition", "id": "cb99af7e-31c4-681c-f517-1d8583a6160d", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "resolved" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "195662009", "display": "Acute viral pharyngitis (disorder)" } ], "text": "Acute viral pharyngitis (disorder)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7b550ac5-164f-b31f-8dc3-5f51afb0b703" }, "onsetDateTime": "2018-01-28T02:33:36-07:00", "abatementDateTime": "2018-02-10T02:33:36-07:00", "recordedDate": "2018-01-28T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:1d104d47-cfff-4070-aed7-dc653f6032d6", "resource": { "resourceType": "Observation", "id": "1d104d47-cfff-4070-aed7-dc653f6032d6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8310-5", "display": "Body temperature" }, { "system": "http://loinc.org", "code": "8331-1", "display": "Oral temperature" } ], "text": "Body temperature" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:7b550ac5-164f-b31f-8dc3-5f51afb0b703" }, "effectiveDateTime": "2018-01-28T02:33:36-07:00", "issued": "2018-01-28T02:33:36.965-07:00", "valueQuantity": { "value": 37.089, "unit": "Cel", "system": "http://unitsofmeasure.org", "code": "Cel" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:dd74de40-cd6c-074a-c9df-e2f5851abdb8", "resource": { "resourceType": "Claim", "id": "dd74de40-cd6c-074a-c9df-e2f5851abdb8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-01-28T02:33:36-07:00", "end": "2018-01-28T02:48:36-07:00" }, "created": "2018-01-28T02:48:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:cb99af7e-31c4-681c-f517-1d8583a6160d" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185345009", "display": "Encounter for symptom" } ], "text": "Encounter for symptom" }, "encounter": [ { "reference": "urn:uuid:7b550ac5-164f-b31f-8dc3-5f51afb0b703" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "195662009", "display": "Acute viral pharyngitis (disorder)" } ], "text": "Acute viral pharyngitis (disorder)" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b93c3b79-8d3b-00ec-ebca-6a822639c606", "resource": { "resourceType": "ExplanationOfBenefit", "id": "b93c3b79-8d3b-00ec-ebca-6a822639c606", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "performer": [ { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "dd74de40-cd6c-074a-c9df-e2f5851abdb8" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-01-28T02:48:36-07:00", "end": "2019-01-28T02:48:36-07:00" }, "created": "2018-01-28T02:48:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:dd74de40-cd6c-074a-c9df-e2f5851abdb8" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:cb99af7e-31c4-681c-f517-1d8583a6160d" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185345009", "display": "Encounter for symptom" } ], "text": "Encounter for symptom" }, "servicedPeriod": { "start": "2018-01-28T02:33:36-07:00", "end": "2018-01-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:7b550ac5-164f-b31f-8dc3-5f51afb0b703" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "195662009", "display": "Acute viral pharyngitis (disorder)" } ], "text": "Acute viral pharyngitis (disorder)" }, "servicedPeriod": { "start": "2018-01-28T02:33:36-07:00", "end": "2018-01-28T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] } } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595", "resource": { "resourceType": "Encounter", "id": "466d50ec-5979-418e-eb91-75af662a4595", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:51451caa-b81d-0e83-ec49-84cd15c1607f", "resource": { "resourceType": "Observation", "id": "51451caa-b81d-0e83-ec49-84cd15c1607f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d7beed5b-1714-ad9a-d5f3-bb6ecee95d23", "resource": { "resourceType": "Observation", "id": "d7beed5b-1714-ad9a-d5f3-bb6ecee95d23", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 3, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f4bd93e2-d968-46c6-98d4-4b3c97d7986f", "resource": { "resourceType": "Observation", "id": "f4bd93e2-d968-46c6-98d4-4b3c97d7986f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:fe297c60-cd65-bc01-a044-380956f6fa61", "resource": { "resourceType": "Observation", "id": "fe297c60-cd65-bc01-a044-380956f6fa61", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6622e25d-61d7-9b6c-49d2-c91ee966aeca", "resource": { "resourceType": "Observation", "id": "6622e25d-61d7-9b6c-49d2-c91ee966aeca", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 79, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 112, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:75a6943f-ecb6-8fba-bdfc-3bdf85a52654", "resource": { "resourceType": "Observation", "id": "75a6943f-ecb6-8fba-bdfc-3bdf85a52654", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 69, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:59f6fa06-02d6-f2cf-9e00-8b90c6fba3c7", "resource": { "resourceType": "Observation", "id": "59f6fa06-02d6-f2cf-9e00-8b90c6fba3c7", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d5025332-240a-66a3-27be-62703cbed987", "resource": { "resourceType": "Observation", "id": "d5025332-240a-66a3-27be-62703cbed987", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 97.94, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f71a6001-e447-986c-9223-880856bd5b60", "resource": { "resourceType": "Observation", "id": "f71a6001-e447-986c-9223-880856bd5b60", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 10.93, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:dce0e9e3-aee8-91fc-ec05-60c5be7ce886", "resource": { "resourceType": "Observation", "id": "dce0e9e3-aee8-91fc-ec05-60c5be7ce886", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 1.02, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:728fdf28-5732-3d67-f949-52ca9773d1d6", "resource": { "resourceType": "Observation", "id": "728fdf28-5732-3d67-f949-52ca9773d1d6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 9.18, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9cfaf5f5-d75d-fee8-c06e-24023f7c0062", "resource": { "resourceType": "Observation", "id": "9cfaf5f5-d75d-fee8-c06e-24023f7c0062", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 141.66, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:fc140a80-ff88-8904-6204-a5754091602c", "resource": { "resourceType": "Observation", "id": "fc140a80-ff88-8904-6204-a5754091602c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 4.78, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:519aac7b-e677-4ef0-adb7-3fdc7dc5b330", "resource": { "resourceType": "Observation", "id": "519aac7b-e677-4ef0-adb7-3fdc7dc5b330", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 108.29, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b4328fcc-d158-392f-ca65-3576cb7010a7", "resource": { "resourceType": "Observation", "id": "b4328fcc-d158-392f-ca65-3576cb7010a7", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 25.36, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:52a3d480-03b5-807f-59cf-ad1d263e948a", "resource": { "resourceType": "Observation", "id": "52a3d480-03b5-807f-59cf-ad1d263e948a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 167.4, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:0fc359fc-a811-d2f5-41a3-da9372350354", "resource": { "resourceType": "Observation", "id": "0fc359fc-a811-d2f5-41a3-da9372350354", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 121.16, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8cb0917d-523f-2766-c48e-d820ea0b660c", "resource": { "resourceType": "Observation", "id": "8cb0917d-523f-2766-c48e-d820ea0b660c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 79.92, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:dff983b9-b0c4-e309-bbbd-05624d0be282", "resource": { "resourceType": "Observation", "id": "dff983b9-b0c4-e309-bbbd-05624d0be282", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 63.25, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c40cfde4-f0d0-355a-84ef-ff5c05bf53d8", "resource": { "resourceType": "Observation", "id": "c40cfde4-f0d0-355a-84ef-ff5c05bf53d8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 9.01, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:316e19dd-5a73-ce40-e873-85cf5aac6743", "resource": { "resourceType": "Observation", "id": "316e19dd-5a73-ce40-e873-85cf5aac6743", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 91.45, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:509b959d-5faa-5271-b5ea-e1d0a4654113", "resource": { "resourceType": "Observation", "id": "509b959d-5faa-5271-b5ea-e1d0a4654113", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:57d0adf5-01e1-3215-d475-a19a2d5bedf0", "resource": { "resourceType": "Observation", "id": "57d0adf5-01e1-3215-d475-a19a2d5bedf0", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:18ec707c-3607-c5a9-cb43-bd9bf8b62465", "resource": { "resourceType": "Procedure", "id": "18ec707c-3607-c5a9-cb43-bd9bf8b62465", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "performedPeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:c727b8c4-1878-d526-789e-7ad729dd1aa2", "resource": { "resourceType": "MedicationRequest", "id": "c727b8c4-1878-d526-789e-7ad729dd1aa2", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "authoredOn": "2018-02-04T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:52114cce-fed2-ed61-77ec-9e6a1f0e747d", "resource": { "resourceType": "Claim", "id": "52114cce-fed2-ed61-77ec-9e6a1f0e747d", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "created": "2018-02-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:c727b8c4-1878-d526-789e-7ad729dd1aa2" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:cecaccc2-1836-27b5-208d-c66bc1ff8dba", "resource": { "resourceType": "MedicationRequest", "id": "cecaccc2-1836-27b5-208d-c66bc1ff8dba", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "authoredOn": "2018-02-04T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:f0f869d7-8aa4-47de-a8d1-fbfbdaf4a48b", "resource": { "resourceType": "Claim", "id": "f0f869d7-8aa4-47de-a8d1-fbfbdaf4a48b", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "created": "2018-02-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:cecaccc2-1836-27b5-208d-c66bc1ff8dba" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" } ] } ], "total": { "value": 326.4, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e5809899-30aa-5427-bf0f-d295d8c1a859", "resource": { "resourceType": "MedicationRequest", "id": "e5809899-30aa-5427-bf0f-d295d8c1a859", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "authoredOn": "2018-02-04T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:c958324a-0349-0bc8-582c-a8a80b42b0c4", "resource": { "resourceType": "Claim", "id": "c958324a-0349-0bc8-582c-a8a80b42b0c4", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "created": "2018-02-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:e5809899-30aa-5427-bf0f-d295d8c1a859" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:f96ab9a7-3b83-df89-dc0f-dd638a3660e8", "resource": { "resourceType": "DiagnosticReport", "id": "f96ab9a7-3b83-df89-dc0f-dd638a3660e8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "result": [ { "reference": "urn:uuid:d5025332-240a-66a3-27be-62703cbed987", "display": "Glucose" }, { "reference": "urn:uuid:f71a6001-e447-986c-9223-880856bd5b60", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:dce0e9e3-aee8-91fc-ec05-60c5be7ce886", "display": "Creatinine" }, { "reference": "urn:uuid:728fdf28-5732-3d67-f949-52ca9773d1d6", "display": "Calcium" }, { "reference": "urn:uuid:9cfaf5f5-d75d-fee8-c06e-24023f7c0062", "display": "Sodium" }, { "reference": "urn:uuid:fc140a80-ff88-8904-6204-a5754091602c", "display": "Potassium" }, { "reference": "urn:uuid:519aac7b-e677-4ef0-adb7-3fdc7dc5b330", "display": "Chloride" }, { "reference": "urn:uuid:b4328fcc-d158-392f-ca65-3576cb7010a7", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:0d75b6ce-9354-50aa-a6b3-0fd84044bae2", "resource": { "resourceType": "DiagnosticReport", "id": "0d75b6ce-9354-50aa-a6b3-0fd84044bae2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" }, "effectiveDateTime": "2018-02-04T02:33:36-07:00", "issued": "2018-02-04T02:33:36.965-07:00", "result": [ { "reference": "urn:uuid:52a3d480-03b5-807f-59cf-ad1d263e948a", "display": "Total Cholesterol" }, { "reference": "urn:uuid:0fc359fc-a811-d2f5-41a3-da9372350354", "display": "Triglycerides" }, { "reference": "urn:uuid:8cb0917d-523f-2766-c48e-d820ea0b660c", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:dff983b9-b0c4-e309-bbbd-05624d0be282", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:c50ebb3a-e5a1-2792-414f-f881827cc775", "resource": { "resourceType": "Claim", "id": "c50ebb3a-e5a1-2792-414f-f881827cc775", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "created": "2018-02-04T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:18ec707c-3607-c5a9-cb43-bd9bf8b62465" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "net": { "value": 420.57, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:3943c488-375e-b6a1-22e0-b96808bc9f72", "resource": { "resourceType": "ExplanationOfBenefit", "id": "3943c488-375e-b6a1-22e0-b96808bc9f72", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "c50ebb3a-e5a1-2792-414f-f881827cc775" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-04T02:48:36-07:00", "end": "2019-02-04T02:48:36-07:00" }, "created": "2018-02-04T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:c50ebb3a-e5a1-2792-414f-f881827cc775" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "servicedPeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:466d50ec-5979-418e-eb91-75af662a4595" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "servicedPeriod": { "start": "2018-02-04T02:33:36-07:00", "end": "2018-02-04T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 420.57, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 84.114, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 336.456, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 420.57, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 420.57, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 336.456, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd", "resource": { "resourceType": "Encounter", "id": "0e57cd4f-c479-dac5-bafa-03753dc902fd", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:52e35fcc-200b-2643-730a-42dba74e27c2", "resource": { "resourceType": "Observation", "id": "52e35fcc-200b-2643-730a-42dba74e27c2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:406e4830-cd4a-cbb5-792d-d92ce0cc507b", "resource": { "resourceType": "Observation", "id": "406e4830-cd4a-cbb5-792d-d92ce0cc507b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 3, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8427af48-7644-e70d-cc3b-cc0a47e3e792", "resource": { "resourceType": "Observation", "id": "8427af48-7644-e70d-cc3b-cc0a47e3e792", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c26cca3c-dd9a-d2d9-7062-2b217b762009", "resource": { "resourceType": "Observation", "id": "c26cca3c-dd9a-d2d9-7062-2b217b762009", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:126a33b5-eeae-0dc8-e94e-61548bb4409e", "resource": { "resourceType": "Observation", "id": "126a33b5-eeae-0dc8-e94e-61548bb4409e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 82, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 122, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:af514226-8a55-746c-6dec-e53e7e35fd29", "resource": { "resourceType": "Observation", "id": "af514226-8a55-746c-6dec-e53e7e35fd29", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 98, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6a5bef64-6905-d341-ba8e-fcd437d18249", "resource": { "resourceType": "Observation", "id": "6a5bef64-6905-d341-ba8e-fcd437d18249", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:496f2577-2263-14ed-57fc-88666c76173f", "resource": { "resourceType": "Observation", "id": "496f2577-2263-14ed-57fc-88666c76173f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 98.59, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:0ad484b3-1dbf-90c9-3be3-08d07df47a19", "resource": { "resourceType": "Observation", "id": "0ad484b3-1dbf-90c9-3be3-08d07df47a19", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 7.52, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2c81f708-a363-3d9f-e072-54ec33ae5a12", "resource": { "resourceType": "Observation", "id": "2c81f708-a363-3d9f-e072-54ec33ae5a12", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 1.07, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:55f6a499-43cc-ccb5-190a-b24790d89438", "resource": { "resourceType": "Observation", "id": "55f6a499-43cc-ccb5-190a-b24790d89438", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 9.14, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:341a1d8c-5cba-f10a-b7e7-45194b92164f", "resource": { "resourceType": "Observation", "id": "341a1d8c-5cba-f10a-b7e7-45194b92164f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 139.01, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a003cd20-3bec-56df-77eb-0b702ecb8bf5", "resource": { "resourceType": "Observation", "id": "a003cd20-3bec-56df-77eb-0b702ecb8bf5", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 4.63, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:495e0a02-9169-0f78-ed65-d7ab121a3a06", "resource": { "resourceType": "Observation", "id": "495e0a02-9169-0f78-ed65-d7ab121a3a06", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 102.67, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a47957e4-e710-7523-9409-fe2cbf52ac41", "resource": { "resourceType": "Observation", "id": "a47957e4-e710-7523-9409-fe2cbf52ac41", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 28.99, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f059ae48-4552-cb79-6ea2-aa50ac6e192b", "resource": { "resourceType": "Observation", "id": "f059ae48-4552-cb79-6ea2-aa50ac6e192b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 175.08, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4350d899-2dae-1fe3-51a6-0e9a9b07a033", "resource": { "resourceType": "Observation", "id": "4350d899-2dae-1fe3-51a6-0e9a9b07a033", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 116.03, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:7a564383-86fa-2e60-8bbd-e43013ecc616", "resource": { "resourceType": "Observation", "id": "7a564383-86fa-2e60-8bbd-e43013ecc616", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 85.19, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:097dcb83-e607-4e84-9213-ed88170ed384", "resource": { "resourceType": "Observation", "id": "097dcb83-e607-4e84-9213-ed88170ed384", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 66.68, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:37f460b7-f2d0-acc3-f8d7-7060dcd8fa03", "resource": { "resourceType": "Observation", "id": "37f460b7-f2d0-acc3-f8d7-7060dcd8fa03", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 5.75, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:910293fd-37c2-53ef-de4b-daf5f7c96314", "resource": { "resourceType": "Observation", "id": "910293fd-37c2-53ef-de4b-daf5f7c96314", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 86.67, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e3026137-e197-cafe-0700-086fb2698d93", "resource": { "resourceType": "Observation", "id": "e3026137-e197-cafe-0700-086fb2698d93", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3636caf3-5360-4b11-efd0-d89c00a49d63", "resource": { "resourceType": "Observation", "id": "3636caf3-5360-4b11-efd0-d89c00a49d63", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:bd491b2a-af81-d1b1-b551-0edf7a40814a", "resource": { "resourceType": "MedicationRequest", "id": "bd491b2a-af81-d1b1-b551-0edf7a40814a", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "authoredOn": "2018-02-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:f918dd66-d464-935b-bb5b-ac6671291318", "resource": { "resourceType": "Claim", "id": "f918dd66-d464-935b-bb5b-ac6671291318", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "created": "2018-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:bd491b2a-af81-d1b1-b551-0edf7a40814a" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:8ec8e60b-ce04-923e-ca35-39a08f8a960f", "resource": { "resourceType": "MedicationRequest", "id": "8ec8e60b-ce04-923e-ca35-39a08f8a960f", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "authoredOn": "2018-02-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:a2c4faef-6d3f-5d42-e3f3-b2f161ab377e", "resource": { "resourceType": "Claim", "id": "a2c4faef-6d3f-5d42-e3f3-b2f161ab377e", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "created": "2018-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:8ec8e60b-ce04-923e-ca35-39a08f8a960f" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" } ] } ], "total": { "value": 117.56, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:c320f12b-de90-3b4c-5c2c-0c9e8c4975ae", "resource": { "resourceType": "MedicationRequest", "id": "c320f12b-de90-3b4c-5c2c-0c9e8c4975ae", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "authoredOn": "2018-02-11T02:33:36-07:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:706b5434-8c4d-46c0-e85f-82101c3f9102", "resource": { "resourceType": "Claim", "id": "706b5434-8c4d-46c0-e85f-82101c3f9102", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "created": "2018-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:c320f12b-de90-3b4c-5c2c-0c9e8c4975ae" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:631aea2c-e89c-3d47-1092-2435a58a6b59", "resource": { "resourceType": "DiagnosticReport", "id": "631aea2c-e89c-3d47-1092-2435a58a6b59", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "result": [ { "reference": "urn:uuid:496f2577-2263-14ed-57fc-88666c76173f", "display": "Glucose" }, { "reference": "urn:uuid:0ad484b3-1dbf-90c9-3be3-08d07df47a19", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:2c81f708-a363-3d9f-e072-54ec33ae5a12", "display": "Creatinine" }, { "reference": "urn:uuid:55f6a499-43cc-ccb5-190a-b24790d89438", "display": "Calcium" }, { "reference": "urn:uuid:341a1d8c-5cba-f10a-b7e7-45194b92164f", "display": "Sodium" }, { "reference": "urn:uuid:a003cd20-3bec-56df-77eb-0b702ecb8bf5", "display": "Potassium" }, { "reference": "urn:uuid:495e0a02-9169-0f78-ed65-d7ab121a3a06", "display": "Chloride" }, { "reference": "urn:uuid:a47957e4-e710-7523-9409-fe2cbf52ac41", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:965fa975-817e-07d1-f017-5b49c0d479b6", "resource": { "resourceType": "DiagnosticReport", "id": "965fa975-817e-07d1-f017-5b49c0d479b6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" }, "effectiveDateTime": "2018-02-11T02:33:36-07:00", "issued": "2018-02-11T02:33:36.965-07:00", "result": [ { "reference": "urn:uuid:f059ae48-4552-cb79-6ea2-aa50ac6e192b", "display": "Total Cholesterol" }, { "reference": "urn:uuid:4350d899-2dae-1fe3-51a6-0e9a9b07a033", "display": "Triglycerides" }, { "reference": "urn:uuid:7a564383-86fa-2e60-8bbd-e43013ecc616", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:097dcb83-e607-4e84-9213-ed88170ed384", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:8c94f387-d9bc-3edd-de38-4fb6b58bac23", "resource": { "resourceType": "Claim", "id": "8c94f387-d9bc-3edd-de38-4fb6b58bac23", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "created": "2018-02-11T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "encounter": [ { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:e71c2904-4c74-2ef7-d823-6e58bd936fd1", "resource": { "resourceType": "ExplanationOfBenefit", "id": "e71c2904-4c74-2ef7-d823-6e58bd936fd1", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "8c94f387-d9bc-3edd-de38-4fb6b58bac23" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-11T02:48:36-07:00", "end": "2019-02-11T02:48:36-07:00" }, "created": "2018-02-11T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:8c94f387-d9bc-3edd-de38-4fb6b58bac23" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185349003", "display": "Encounter for check up (procedure)" } ], "text": "Encounter for check up (procedure)" }, "servicedPeriod": { "start": "2018-02-11T02:33:36-07:00", "end": "2018-02-11T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:0e57cd4f-c479-dac5-bafa-03753dc902fd" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:5843eb07-e2af-2182-50d3-7be5ad122f84", "resource": { "resourceType": "Encounter", "id": "5843eb07-e2af-2182-50d3-7be5ad122f84", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:cb519dc4-a32f-edb7-038f-ebabe6ebf62d", "resource": { "resourceType": "Procedure", "id": "cb519dc4-a32f-edb7-038f-ebabe6ebf62d", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:5843eb07-e2af-2182-50d3-7be5ad122f84" }, "performedPeriod": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:46:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:d208004c-f09a-15ed-218f-6d7c4b7217d8", "resource": { "resourceType": "Procedure", "id": "d208004c-f09a-15ed-218f-6d7c4b7217d8", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:5843eb07-e2af-2182-50d3-7be5ad122f84" }, "performedPeriod": { "start": "2018-03-04T02:33:36-07:00", "end": "2018-03-04T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:815eedb0-f196-f51a-7e60-e6e644ea04c8", "resource": { "resourceType": "Claim", "id": "815eedb0-f196-f51a-7e60-e6e644ea04c8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:48:36-07:00" }, "created": "2018-02-25T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:cb519dc4-a32f-edb7-038f-ebabe6ebf62d" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:d208004c-f09a-15ed-218f-6d7c4b7217d8" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:5843eb07-e2af-2182-50d3-7be5ad122f84" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3573.86, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2271.86, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:c5cd9b4b-75e1-c099-784e-4ba4ab0baae0", "resource": { "resourceType": "ExplanationOfBenefit", "id": "c5cd9b4b-75e1-c099-784e-4ba4ab0baae0", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "815eedb0-f196-f51a-7e60-e6e644ea04c8" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-02-25T02:48:36-07:00", "end": "2019-02-25T02:48:36-07:00" }, "created": "2018-02-25T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:815eedb0-f196-f51a-7e60-e6e644ea04c8" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:5843eb07-e2af-2182-50d3-7be5ad122f84" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3573.86, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 714.772, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2859.088, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3573.86, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3573.86, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-02-25T02:33:36-07:00", "end": "2018-02-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2271.86, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 454.37200000000009, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1817.4880000000003, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2271.86, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2271.86, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4676.576000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943", "resource": { "resourceType": "Encounter", "id": "4bc9e857-0a6b-622d-3530-095bfdba0943", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:a83492c7-f253-6e45-505e-fa83663eda3f", "resource": { "resourceType": "Procedure", "id": "a83492c7-f253-6e45-505e-fa83663eda3f", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943" }, "performedPeriod": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:cf936559-0283-ba81-5ede-149b1f7c7766", "resource": { "resourceType": "Procedure", "id": "cf936559-0283-ba81-5ede-149b1f7c7766", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943" }, "performedPeriod": { "start": "2018-04-08T03:33:36-06:00", "end": "2018-04-08T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:cf77b2e1-2e90-5874-4ab4-45a8d7175bfd", "resource": { "resourceType": "MedicationRequest", "id": "cf77b2e1-2e90-5874-4ab4-45a8d7175bfd", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "1000126", "display": "1 ML medroxyPROGESTERone acetate 150 MG/ML Injection" } ], "text": "1 ML medroxyPROGESTERone acetate 150 MG/ML Injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943" }, "authoredOn": "2018-04-01T03:33:36-06:00", "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:6480b2eb-3755-f8ab-b902-34e16dcae99a", "resource": { "resourceType": "Claim", "id": "6480b2eb-3755-f8ab-b902-34e16dcae99a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "created": "2018-04-01T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:cf77b2e1-2e90-5874-4ab4-45a8d7175bfd" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943" } ] } ], "total": { "value": 154.95, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:864e9384-eaec-f9ee-aee6-daa03a335308", "resource": { "resourceType": "Claim", "id": "864e9384-eaec-f9ee-aee6-daa03a335308", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "created": "2018-04-01T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:a83492c7-f253-6e45-505e-fa83663eda3f" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:cf936559-0283-ba81-5ede-149b1f7c7766" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2695.61, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2953.64, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:82b45457-d227-a8c5-e301-239ec190d16d", "resource": { "resourceType": "ExplanationOfBenefit", "id": "82b45457-d227-a8c5-e301-239ec190d16d", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "864e9384-eaec-f9ee-aee6-daa03a335308" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-04-01T03:48:36-06:00", "end": "2019-04-01T03:48:36-06:00" }, "created": "2018-04-01T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:864e9384-eaec-f9ee-aee6-daa03a335308" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "servicedPeriod": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:4bc9e857-0a6b-622d-3530-095bfdba0943" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2695.61, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 539.1220000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2156.4880000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2695.61, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2695.61, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-04-01T03:33:36-06:00", "end": "2018-04-01T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2953.64, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 590.728, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2362.912, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2953.64, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2953.64, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4519.4, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af", "resource": { "resourceType": "Encounter", "id": "3fc3bef7-d636-733d-7b8c-13654ba687af", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:ca30107d-3175-14eb-f6f6-19fcfc19b812", "resource": { "resourceType": "Observation", "id": "ca30107d-3175-14eb-f6f6-19fcfc19b812", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:58392851-fd0f-ff31-2dab-90e94adc3025", "resource": { "resourceType": "Observation", "id": "58392851-fd0f-ff31-2dab-90e94adc3025", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 2, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5a1a504b-8261-81c0-7ad7-935608770ede", "resource": { "resourceType": "Observation", "id": "5a1a504b-8261-81c0-7ad7-935608770ede", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5d14f1fd-86da-775d-565d-a59030b94904", "resource": { "resourceType": "Observation", "id": "5d14f1fd-86da-775d-565d-a59030b94904", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4ee0cd4b-7c42-7ae6-e781-dfb6e89f8fcd", "resource": { "resourceType": "Observation", "id": "4ee0cd4b-7c42-7ae6-e781-dfb6e89f8fcd", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 71, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 128, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c9d0843b-8157-e897-2cdc-8fb349817dc7", "resource": { "resourceType": "Observation", "id": "c9d0843b-8157-e897-2cdc-8fb349817dc7", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 60, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:47929011-a098-2f89-4e91-866455ea2dfa", "resource": { "resourceType": "Observation", "id": "47929011-a098-2f89-4e91-866455ea2dfa", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8663f39e-b07d-377c-0a92-841e5240a14e", "resource": { "resourceType": "Observation", "id": "8663f39e-b07d-377c-0a92-841e5240a14e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 85.06, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c40b3ed0-9a04-ded5-1b37-78540ec6962a", "resource": { "resourceType": "Observation", "id": "c40b3ed0-9a04-ded5-1b37-78540ec6962a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 19.06, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:3847b78e-d423-d4e9-25ee-8891afbab65e", "resource": { "resourceType": "Observation", "id": "3847b78e-d423-d4e9-25ee-8891afbab65e", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 0.93, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:06c9bbc7-5515-547b-8571-12af85d53f42", "resource": { "resourceType": "Observation", "id": "06c9bbc7-5515-547b-8571-12af85d53f42", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 9.58, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a486b0c6-998d-8283-f00a-1e445324881f", "resource": { "resourceType": "Observation", "id": "a486b0c6-998d-8283-f00a-1e445324881f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 142.62, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e68c13cc-35ec-7531-124d-f15848c10acc", "resource": { "resourceType": "Observation", "id": "e68c13cc-35ec-7531-124d-f15848c10acc", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 4.78, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f69a7fd8-7aec-2730-3069-bc5c6726d29c", "resource": { "resourceType": "Observation", "id": "f69a7fd8-7aec-2730-3069-bc5c6726d29c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 109.57, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a50abcc8-5e23-db2f-672d-915e1f7c7577", "resource": { "resourceType": "Observation", "id": "a50abcc8-5e23-db2f-672d-915e1f7c7577", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 27.63, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:bd0c2ba5-235f-b39c-5962-1a76ededfb46", "resource": { "resourceType": "Observation", "id": "bd0c2ba5-235f-b39c-5962-1a76ededfb46", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 170.91, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:716d2439-4e73-82b2-c91e-c38796c45794", "resource": { "resourceType": "Observation", "id": "716d2439-4e73-82b2-c91e-c38796c45794", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 144.92, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d21317e4-8a1c-16b5-96ec-4b260f485971", "resource": { "resourceType": "Observation", "id": "d21317e4-8a1c-16b5-96ec-4b260f485971", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 74.35, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b6518db2-4ff2-867c-dcca-eed2630a359a", "resource": { "resourceType": "Observation", "id": "b6518db2-4ff2-867c-dcca-eed2630a359a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 67.57, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:33ac4ba4-dba9-4230-c8f2-a66cf4150ed6", "resource": { "resourceType": "Observation", "id": "33ac4ba4-dba9-4230-c8f2-a66cf4150ed6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 12.33, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b4824155-f902-ec52-9e97-22e9cb2820a2", "resource": { "resourceType": "Observation", "id": "b4824155-f902-ec52-9e97-22e9cb2820a2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 138.25, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:03e407c3-746f-3f02-f160-8444b2857010", "resource": { "resourceType": "Observation", "id": "03e407c3-746f-3f02-f160-8444b2857010", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:34b20a60-d23a-817d-15e4-fab3148026eb", "resource": { "resourceType": "Observation", "id": "34b20a60-d23a-817d-15e4-fab3148026eb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:874bad73-a400-51e7-9d7e-c719fcf2fd1f", "resource": { "resourceType": "Procedure", "id": "874bad73-a400-51e7-9d7e-c719fcf2fd1f", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "performedPeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:4bda059e-97da-c74a-f99d-4ec1bc695457", "resource": { "resourceType": "MedicationRequest", "id": "4bda059e-97da-c74a-f99d-4ec1bc695457", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "authoredOn": "2018-04-22T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:fcd5f4bd-acd3-2fde-7967-364cfb4be9e8", "resource": { "resourceType": "Claim", "id": "fcd5f4bd-acd3-2fde-7967-364cfb4be9e8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "created": "2018-04-22T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:4bda059e-97da-c74a-f99d-4ec1bc695457" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:4712bff2-d4a9-ef8a-576e-b7e4250c42ed", "resource": { "resourceType": "MedicationRequest", "id": "4712bff2-d4a9-ef8a-576e-b7e4250c42ed", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "authoredOn": "2018-04-22T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:979372ff-785f-42aa-8b98-a8b2f55836b2", "resource": { "resourceType": "Claim", "id": "979372ff-785f-42aa-8b98-a8b2f55836b2", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "created": "2018-04-22T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:4712bff2-d4a9-ef8a-576e-b7e4250c42ed" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" } ] } ], "total": { "value": 21.96, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:d502a4d1-9b3e-e912-5269-e1963e113b55", "resource": { "resourceType": "MedicationRequest", "id": "d502a4d1-9b3e-e912-5269-e1963e113b55", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "authoredOn": "2018-04-22T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b8097163-c3cc-fd53-8df5-ff143a5958aa", "resource": { "resourceType": "Claim", "id": "b8097163-c3cc-fd53-8df5-ff143a5958aa", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "created": "2018-04-22T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:d502a4d1-9b3e-e912-5269-e1963e113b55" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6c3bbcc4-f312-7c3c-38e5-ac8a9bc1e55f", "resource": { "resourceType": "Immunization", "id": "6c3bbcc4-f312-7c3c-38e5-ac8a9bc1e55f", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "occurrenceDateTime": "2018-04-22T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:c01d1373-1dac-40a3-78b9-eead00c67260", "resource": { "resourceType": "DiagnosticReport", "id": "c01d1373-1dac-40a3-78b9-eead00c67260", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:8663f39e-b07d-377c-0a92-841e5240a14e", "display": "Glucose" }, { "reference": "urn:uuid:c40b3ed0-9a04-ded5-1b37-78540ec6962a", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:3847b78e-d423-d4e9-25ee-8891afbab65e", "display": "Creatinine" }, { "reference": "urn:uuid:06c9bbc7-5515-547b-8571-12af85d53f42", "display": "Calcium" }, { "reference": "urn:uuid:a486b0c6-998d-8283-f00a-1e445324881f", "display": "Sodium" }, { "reference": "urn:uuid:e68c13cc-35ec-7531-124d-f15848c10acc", "display": "Potassium" }, { "reference": "urn:uuid:f69a7fd8-7aec-2730-3069-bc5c6726d29c", "display": "Chloride" }, { "reference": "urn:uuid:a50abcc8-5e23-db2f-672d-915e1f7c7577", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:bf22bbeb-26e7-7765-84d5-212a6180887c", "resource": { "resourceType": "DiagnosticReport", "id": "bf22bbeb-26e7-7765-84d5-212a6180887c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" }, "effectiveDateTime": "2018-04-22T03:33:36-06:00", "issued": "2018-04-22T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:bd0c2ba5-235f-b39c-5962-1a76ededfb46", "display": "Total Cholesterol" }, { "reference": "urn:uuid:716d2439-4e73-82b2-c91e-c38796c45794", "display": "Triglycerides" }, { "reference": "urn:uuid:d21317e4-8a1c-16b5-96ec-4b260f485971", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:b6518db2-4ff2-867c-dcca-eed2630a359a", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:81cccd81-e962-cfaa-9b29-9badcf271c48", "resource": { "resourceType": "Claim", "id": "81cccd81-e962-cfaa-9b29-9badcf271c48", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "created": "2018-04-22T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:6c3bbcc4-f312-7c3c-38e5-ac8a9bc1e55f" } } ], "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:874bad73-a400-51e7-9d7e-c719fcf2fd1f" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "net": { "value": 857.41, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:c7396073-825b-eb6d-d4f9-320e5eb6dc43", "resource": { "resourceType": "ExplanationOfBenefit", "id": "c7396073-825b-eb6d-d4f9-320e5eb6dc43", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "81cccd81-e962-cfaa-9b29-9badcf271c48" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-04-22T03:48:36-06:00", "end": "2019-04-22T03:48:36-06:00" }, "created": "2018-04-22T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:81cccd81-e962-cfaa-9b29-9badcf271c48" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:3fc3bef7-d636-733d-7b8c-13654ba687af" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "430193006", "display": "Medication Reconciliation (procedure)" } ], "text": "Medication Reconciliation (procedure)" }, "servicedPeriod": { "start": "2018-04-22T03:33:36-06:00", "end": "2018-04-22T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 857.41, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 171.482, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 685.928, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 857.41, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 857.41, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 798.344, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:56322b3c-c144-d43b-8d10-03bd5d4ebd3a", "resource": { "resourceType": "Encounter", "id": "56322b3c-c144-d43b-8d10-03bd5d4ebd3a", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:92e62127-34b5-783a-9098-4e83bf9e68ee", "resource": { "resourceType": "Procedure", "id": "92e62127-34b5-783a-9098-4e83bf9e68ee", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:56322b3c-c144-d43b-8d10-03bd5d4ebd3a" }, "performedPeriod": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:5f85e623-fc89-736c-db4c-3871c37a72f3", "resource": { "resourceType": "Procedure", "id": "5f85e623-fc89-736c-db4c-3871c37a72f3", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:56322b3c-c144-d43b-8d10-03bd5d4ebd3a" }, "performedPeriod": { "start": "2018-06-03T03:33:36-06:00", "end": "2018-06-03T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:8a132bdc-ff3a-a935-b2a5-c50fbd8477da", "resource": { "resourceType": "Claim", "id": "8a132bdc-ff3a-a935-b2a5-c50fbd8477da", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" }, "created": "2018-05-27T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:92e62127-34b5-783a-9098-4e83bf9e68ee" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:5f85e623-fc89-736c-db4c-3871c37a72f3" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:56322b3c-c144-d43b-8d10-03bd5d4ebd3a" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2389.03, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3541.28, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:56204c09-d28d-721a-90fc-69d93b138a92", "resource": { "resourceType": "ExplanationOfBenefit", "id": "56204c09-d28d-721a-90fc-69d93b138a92", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "8a132bdc-ff3a-a935-b2a5-c50fbd8477da" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-05-27T03:48:36-06:00", "end": "2019-05-27T03:48:36-06:00" }, "created": "2018-05-27T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:8a132bdc-ff3a-a935-b2a5-c50fbd8477da" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:56322b3c-c144-d43b-8d10-03bd5d4ebd3a" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2389.03, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 477.80600000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1911.2240000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2389.03, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2389.03, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-05-27T03:33:36-06:00", "end": "2018-05-27T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3541.28, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 708.2560000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2833.0240000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3541.28, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3541.28, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4744.2480000000009, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:4f3eb403-0dab-61cb-2c82-f5e7cc6b940b", "resource": { "resourceType": "Encounter", "id": "4f3eb403-0dab-61cb-2c82-f5e7cc6b940b", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:85aff596-9115-e963-a60f-c0f2ab18891b", "resource": { "resourceType": "Procedure", "id": "85aff596-9115-e963-a60f-c0f2ab18891b", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4f3eb403-0dab-61cb-2c82-f5e7cc6b940b" }, "performedPeriod": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:bbd6911b-d7aa-59ed-6bc4-5576de2c9aa5", "resource": { "resourceType": "Procedure", "id": "bbd6911b-d7aa-59ed-6bc4-5576de2c9aa5", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:4f3eb403-0dab-61cb-2c82-f5e7cc6b940b" }, "performedPeriod": { "start": "2018-09-02T03:33:36-06:00", "end": "2018-09-02T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:4d20ccc6-9f85-0b29-eb49-0a33b86ec3f7", "resource": { "resourceType": "Claim", "id": "4d20ccc6-9f85-0b29-eb49-0a33b86ec3f7", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" }, "created": "2018-08-26T03:49:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:85aff596-9115-e963-a60f-c0f2ab18891b" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:bbd6911b-d7aa-59ed-6bc4-5576de2c9aa5" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:4f3eb403-0dab-61cb-2c82-f5e7cc6b940b" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2255.73, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 4133.33, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b7f92d3d-3229-aa90-d1a4-3edc75795b74", "resource": { "resourceType": "ExplanationOfBenefit", "id": "b7f92d3d-3229-aa90-d1a4-3edc75795b74", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "4d20ccc6-9f85-0b29-eb49-0a33b86ec3f7" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-08-26T03:49:36-06:00", "end": "2019-08-26T03:49:36-06:00" }, "created": "2018-08-26T03:49:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:4d20ccc6-9f85-0b29-eb49-0a33b86ec3f7" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:4f3eb403-0dab-61cb-2c82-f5e7cc6b940b" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2255.73, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 451.146, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1804.584, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2255.73, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2255.73, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-08-26T03:33:36-06:00", "end": "2018-08-26T03:49:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 4133.33, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 826.666, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3306.664, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 4133.33, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 4133.33, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5111.2480000000009, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:88ed6368-9532-f696-42fc-3006189e8972", "resource": { "resourceType": "Encounter", "id": "88ed6368-9532-f696-42fc-3006189e8972", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d6f5c38f-c82c-6a2e-560d-96686d62c965", "resource": { "resourceType": "Procedure", "id": "d6f5c38f-c82c-6a2e-560d-96686d62c965", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:88ed6368-9532-f696-42fc-3006189e8972" }, "performedPeriod": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:45:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:ccd499a2-7d5c-9c93-d510-854573bbd93c", "resource": { "resourceType": "Procedure", "id": "ccd499a2-7d5c-9c93-d510-854573bbd93c", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:88ed6368-9532-f696-42fc-3006189e8972" }, "performedPeriod": { "start": "2018-12-02T02:33:36-07:00", "end": "2018-12-02T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:b325eed1-0a6f-5944-2368-3c238c44bb0b", "resource": { "resourceType": "Claim", "id": "b325eed1-0a6f-5944-2368-3c238c44bb0b", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:48:36-07:00" }, "created": "2018-11-25T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:d6f5c38f-c82c-6a2e-560d-96686d62c965" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:ccd499a2-7d5c-9c93-d510-854573bbd93c" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:88ed6368-9532-f696-42fc-3006189e8972" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 1541.47, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2011.34, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:372d9467-7f5a-b44f-7411-dfc2387dace9", "resource": { "resourceType": "ExplanationOfBenefit", "id": "372d9467-7f5a-b44f-7411-dfc2387dace9", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "b325eed1-0a6f-5944-2368-3c238c44bb0b" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2018-11-25T02:48:36-07:00", "end": "2019-11-25T02:48:36-07:00" }, "created": "2018-11-25T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:b325eed1-0a6f-5944-2368-3c238c44bb0b" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:88ed6368-9532-f696-42fc-3006189e8972" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 1541.47, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 308.29400000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1233.1760000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 1541.47, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 1541.47, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2018-11-25T02:33:36-07:00", "end": "2018-11-25T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2011.34, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 402.26800000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1609.0720000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2011.34, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2011.34, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 2842.2480000000007, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:fcfa87d4-45ca-9ed2-b391-4e4933393b1b", "resource": { "resourceType": "Encounter", "id": "fcfa87d4-45ca-9ed2-b391-4e4933393b1b", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:f5540405-8612-bfbe-985a-82c163c5d071", "resource": { "resourceType": "Procedure", "id": "f5540405-8612-bfbe-985a-82c163c5d071", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:fcfa87d4-45ca-9ed2-b391-4e4933393b1b" }, "performedPeriod": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:1255d3fc-f85e-94de-d9a9-3bc4bd7568f0", "resource": { "resourceType": "Procedure", "id": "1255d3fc-f85e-94de-d9a9-3bc4bd7568f0", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:fcfa87d4-45ca-9ed2-b391-4e4933393b1b" }, "performedPeriod": { "start": "2019-03-03T02:33:36-07:00", "end": "2019-03-03T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:45e6ba9e-2dd4-2017-2d9f-d97a631b4ab0", "resource": { "resourceType": "Claim", "id": "45e6ba9e-2dd4-2017-2d9f-d97a631b4ab0", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" }, "created": "2019-02-24T02:52:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:f5540405-8612-bfbe-985a-82c163c5d071" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:1255d3fc-f85e-94de-d9a9-3bc4bd7568f0" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:fcfa87d4-45ca-9ed2-b391-4e4933393b1b" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2745.02, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2120.57, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:bc8d03c5-addd-a4f1-2fa1-a6bd6d31e907", "resource": { "resourceType": "ExplanationOfBenefit", "id": "bc8d03c5-addd-a4f1-2fa1-a6bd6d31e907", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "45e6ba9e-2dd4-2017-2d9f-d97a631b4ab0" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-02-24T02:52:36-07:00", "end": "2020-02-24T02:52:36-07:00" }, "created": "2019-02-24T02:52:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:45e6ba9e-2dd4-2017-2d9f-d97a631b4ab0" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:fcfa87d4-45ca-9ed2-b391-4e4933393b1b" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2745.02, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 549.004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2196.016, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2745.02, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2745.02, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-02-24T02:33:36-07:00", "end": "2019-02-24T02:52:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2120.57, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 424.11400000000006, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1696.4560000000002, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2120.57, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2120.57, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3892.472, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7", "resource": { "resourceType": "Encounter", "id": "e2d292a1-3413-3a55-ee6c-019ae7d955e7", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:64ab013c-a385-3498-91b5-17051600e584", "resource": { "resourceType": "Observation", "id": "64ab013c-a385-3498-91b5-17051600e584", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4263a558-e0b4-abb8-304e-25c3b714e839", "resource": { "resourceType": "Observation", "id": "4263a558-e0b4-abb8-304e-25c3b714e839", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 2, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a6ce8e83-3497-a1e4-ad32-7caa0eb39eac", "resource": { "resourceType": "Observation", "id": "a6ce8e83-3497-a1e4-ad32-7caa0eb39eac", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:0bd6d161-64da-8e41-d2cb-a809407acc2f", "resource": { "resourceType": "Observation", "id": "0bd6d161-64da-8e41-d2cb-a809407acc2f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:aebdb44d-9869-4feb-2b46-826957318b69", "resource": { "resourceType": "Observation", "id": "aebdb44d-9869-4feb-2b46-826957318b69", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 88, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 121, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:71259127-f765-cd39-7a5c-1c740ca84935", "resource": { "resourceType": "Observation", "id": "71259127-f765-cd39-7a5c-1c740ca84935", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 93, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:31088066-cb52-c344-abac-b03548e309c9", "resource": { "resourceType": "Observation", "id": "31088066-cb52-c344-abac-b03548e309c9", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:dd062171-8b9d-89aa-5ffa-1380e1c05c1b", "resource": { "resourceType": "Observation", "id": "dd062171-8b9d-89aa-5ffa-1380e1c05c1b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 79.48, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2555142c-9419-ce8f-9672-5db49a919f7f", "resource": { "resourceType": "Observation", "id": "2555142c-9419-ce8f-9672-5db49a919f7f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 18.5, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:8959f7d6-5aae-8ee4-c512-b4a0d33f7f94", "resource": { "resourceType": "Observation", "id": "8959f7d6-5aae-8ee4-c512-b4a0d33f7f94", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 0.92, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9faf0311-77a3-ceeb-c735-74c2fadfca61", "resource": { "resourceType": "Observation", "id": "9faf0311-77a3-ceeb-c735-74c2fadfca61", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 9.29, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:1f848940-1cf4-d6fa-8ade-28b7505004ba", "resource": { "resourceType": "Observation", "id": "1f848940-1cf4-d6fa-8ade-28b7505004ba", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 136.88, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:47f40118-1502-f87e-3789-03ee06ba60e8", "resource": { "resourceType": "Observation", "id": "47f40118-1502-f87e-3789-03ee06ba60e8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 4.55, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:79646070-bc41-1f42-836a-d49daa20fb88", "resource": { "resourceType": "Observation", "id": "79646070-bc41-1f42-836a-d49daa20fb88", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 102.76, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f7b7e15b-d430-b2f1-1969-a0f8eb6582b3", "resource": { "resourceType": "Observation", "id": "f7b7e15b-d430-b2f1-1969-a0f8eb6582b3", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 23.46, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f6e8847a-7c8c-8cd9-d1e5-63a07a01ab5f", "resource": { "resourceType": "Observation", "id": "f6e8847a-7c8c-8cd9-d1e5-63a07a01ab5f", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 189.69, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:f839e48b-0a07-05f1-45eb-9b5996071904", "resource": { "resourceType": "Observation", "id": "f839e48b-0a07-05f1-45eb-9b5996071904", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 105.41, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a17c2f45-14cc-611d-16e7-a1ffc5439b82", "resource": { "resourceType": "Observation", "id": "a17c2f45-14cc-611d-16e7-a1ffc5439b82", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 93.7, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:33455765-b44b-15af-7f8c-febbecd0e741", "resource": { "resourceType": "Observation", "id": "33455765-b44b-15af-7f8c-febbecd0e741", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 74.91, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:83c2d40b-f5d7-be31-34d8-2771bb252b99", "resource": { "resourceType": "Observation", "id": "83c2d40b-f5d7-be31-34d8-2771bb252b99", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 14.7, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6b178143-b8da-af61-cad5-657d302c2b74", "resource": { "resourceType": "Observation", "id": "6b178143-b8da-af61-cad5-657d302c2b74", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 154, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:315e75e0-0991-7b7c-2fa4-d19e6f46bc32", "resource": { "resourceType": "Observation", "id": "315e75e0-0991-7b7c-2fa4-d19e6f46bc32", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:36a4e28c-234e-e5bf-0b2d-9b304c88cecc", "resource": { "resourceType": "Observation", "id": "36a4e28c-234e-e5bf-0b2d-9b304c88cecc", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:77ba4e22-88c8-0a2a-0a62-0ea0016c673b", "resource": { "resourceType": "MedicationRequest", "id": "77ba4e22-88c8-0a2a-0a62-0ea0016c673b", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "authoredOn": "2019-04-28T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:10d7c33e-34a5-bd87-2519-0f1c97b2261a", "resource": { "resourceType": "Claim", "id": "10d7c33e-34a5-bd87-2519-0f1c97b2261a", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "created": "2019-04-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:77ba4e22-88c8-0a2a-0a62-0ea0016c673b" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9613c30e-227d-69aa-8c98-f78b398e488a", "resource": { "resourceType": "MedicationRequest", "id": "9613c30e-227d-69aa-8c98-f78b398e488a", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "authoredOn": "2019-04-28T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:42a2116b-38c4-e9f9-223b-16bc2ecb4255", "resource": { "resourceType": "Claim", "id": "42a2116b-38c4-e9f9-223b-16bc2ecb4255", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "created": "2019-04-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:9613c30e-227d-69aa-8c98-f78b398e488a" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" } ] } ], "total": { "value": 555.43, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:283bae2b-9389-2c2e-884e-3ae0bd795655", "resource": { "resourceType": "MedicationRequest", "id": "283bae2b-9389-2c2e-884e-3ae0bd795655", "status": "stopped", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "authoredOn": "2019-04-28T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:d0fc8fb8-fde7-995b-36d2-003dec54d116", "resource": { "resourceType": "Claim", "id": "d0fc8fb8-fde7-995b-36d2-003dec54d116", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "created": "2019-04-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:283bae2b-9389-2c2e-884e-3ae0bd795655" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:24c9f2dc-f9c6-8b2e-910b-d71bab82c9ba", "resource": { "resourceType": "Immunization", "id": "24c9f2dc-f9c6-8b2e-910b-d71bab82c9ba", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "occurrenceDateTime": "2019-04-28T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:e12d53e0-7a49-5176-1391-f503b7de8d1d", "resource": { "resourceType": "DiagnosticReport", "id": "e12d53e0-7a49-5176-1391-f503b7de8d1d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:dd062171-8b9d-89aa-5ffa-1380e1c05c1b", "display": "Glucose" }, { "reference": "urn:uuid:2555142c-9419-ce8f-9672-5db49a919f7f", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:8959f7d6-5aae-8ee4-c512-b4a0d33f7f94", "display": "Creatinine" }, { "reference": "urn:uuid:9faf0311-77a3-ceeb-c735-74c2fadfca61", "display": "Calcium" }, { "reference": "urn:uuid:1f848940-1cf4-d6fa-8ade-28b7505004ba", "display": "Sodium" }, { "reference": "urn:uuid:47f40118-1502-f87e-3789-03ee06ba60e8", "display": "Potassium" }, { "reference": "urn:uuid:79646070-bc41-1f42-836a-d49daa20fb88", "display": "Chloride" }, { "reference": "urn:uuid:f7b7e15b-d430-b2f1-1969-a0f8eb6582b3", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:ecbd64d3-a240-8be5-1377-a52894101738", "resource": { "resourceType": "DiagnosticReport", "id": "ecbd64d3-a240-8be5-1377-a52894101738", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" }, "effectiveDateTime": "2019-04-28T03:33:36-06:00", "issued": "2019-04-28T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:f6e8847a-7c8c-8cd9-d1e5-63a07a01ab5f", "display": "Total Cholesterol" }, { "reference": "urn:uuid:f839e48b-0a07-05f1-45eb-9b5996071904", "display": "Triglycerides" }, { "reference": "urn:uuid:a17c2f45-14cc-611d-16e7-a1ffc5439b82", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:33455765-b44b-15af-7f8c-febbecd0e741", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:36ef952e-a49f-dc17-a209-ac24c3463eca", "resource": { "resourceType": "Claim", "id": "36ef952e-a49f-dc17-a209-ac24c3463eca", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "created": "2019-04-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:24c9f2dc-f9c6-8b2e-910b-d71bab82c9ba" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:6fc1fe99-ce0e-33d2-6440-b2e781f57734", "resource": { "resourceType": "ExplanationOfBenefit", "id": "6fc1fe99-ce0e-33d2-6440-b2e781f57734", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "36ef952e-a49f-dc17-a209-ac24c3463eca" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-04-28T03:48:36-06:00", "end": "2020-04-28T03:48:36-06:00" }, "created": "2019-04-28T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:36ef952e-a49f-dc17-a209-ac24c3463eca" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:e2d292a1-3413-3a55-ee6c-019ae7d955e7" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2019-04-28T03:33:36-06:00", "end": "2019-04-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 112.41600000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:8956cb06-c436-438f-24fa-eced23a64ca4", "resource": { "resourceType": "Encounter", "id": "8956cb06-c436-438f-24fa-eced23a64ca4", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:d5976808-edd0-cd39-ac6d-6dacffecfe76", "resource": { "resourceType": "Procedure", "id": "d5976808-edd0-cd39-ac6d-6dacffecfe76", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:8956cb06-c436-438f-24fa-eced23a64ca4" }, "performedPeriod": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:44:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:6c871b5e-85ba-df34-b950-e1581655dbd6", "resource": { "resourceType": "Procedure", "id": "6c871b5e-85ba-df34-b950-e1581655dbd6", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:8956cb06-c436-438f-24fa-eced23a64ca4" }, "performedPeriod": { "start": "2019-06-02T03:33:36-06:00", "end": "2019-06-02T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:f251ccd1-2006-3ba0-9054-9cc1cfa846a9", "resource": { "resourceType": "Claim", "id": "f251ccd1-2006-3ba0-9054-9cc1cfa846a9", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:48:36-06:00" }, "created": "2019-05-26T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:d5976808-edd0-cd39-ac6d-6dacffecfe76" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:6c871b5e-85ba-df34-b950-e1581655dbd6" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:8956cb06-c436-438f-24fa-eced23a64ca4" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 5230.4, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3825.83, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:779d193e-f212-6fde-5f9e-389b2c9c80ad", "resource": { "resourceType": "ExplanationOfBenefit", "id": "779d193e-f212-6fde-5f9e-389b2c9c80ad", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "f251ccd1-2006-3ba0-9054-9cc1cfa846a9" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-05-26T03:48:36-06:00", "end": "2020-05-26T03:48:36-06:00" }, "created": "2019-05-26T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:f251ccd1-2006-3ba0-9054-9cc1cfa846a9" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:8956cb06-c436-438f-24fa-eced23a64ca4" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 5230.4, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 1046.08, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 4184.32, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 5230.4, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 5230.4, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-05-26T03:33:36-06:00", "end": "2019-05-26T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3825.83, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 765.166, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 3060.664, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3825.83, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3825.83, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 7244.984, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:086f02f6-52a1-6052-0dcb-2be3553ea6de", "resource": { "resourceType": "Encounter", "id": "086f02f6-52a1-6052-0dcb-2be3553ea6de", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:1f5ed344-fcc2-4c6a-094d-199b8afb7f1b", "resource": { "resourceType": "Procedure", "id": "1f5ed344-fcc2-4c6a-094d-199b8afb7f1b", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:086f02f6-52a1-6052-0dcb-2be3553ea6de" }, "performedPeriod": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:45:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:00fa014f-449a-8edf-5550-c5bf8ff9fc09", "resource": { "resourceType": "Procedure", "id": "00fa014f-449a-8edf-5550-c5bf8ff9fc09", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:086f02f6-52a1-6052-0dcb-2be3553ea6de" }, "performedPeriod": { "start": "2019-09-01T03:33:36-06:00", "end": "2019-09-01T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:77903222-bfc3-9e3b-9fea-e575632e9b37", "resource": { "resourceType": "Claim", "id": "77903222-bfc3-9e3b-9fea-e575632e9b37", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:48:36-06:00" }, "created": "2019-08-25T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:1f5ed344-fcc2-4c6a-094d-199b8afb7f1b" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:00fa014f-449a-8edf-5550-c5bf8ff9fc09" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:086f02f6-52a1-6052-0dcb-2be3553ea6de" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3508.26, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3614.93, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:4f36a608-c86a-119a-5145-3e7dd7c40183", "resource": { "resourceType": "ExplanationOfBenefit", "id": "4f36a608-c86a-119a-5145-3e7dd7c40183", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "77903222-bfc3-9e3b-9fea-e575632e9b37" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-08-25T03:48:36-06:00", "end": "2020-08-25T03:48:36-06:00" }, "created": "2019-08-25T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:77903222-bfc3-9e3b-9fea-e575632e9b37" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:086f02f6-52a1-6052-0dcb-2be3553ea6de" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3508.26, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 701.652, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2806.608, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3508.26, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3508.26, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-08-25T03:33:36-06:00", "end": "2019-08-25T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3614.93, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 722.986, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2891.944, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3614.93, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3614.93, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 5698.552, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:ae04a71d-a2d1-adb4-a039-c9f4d24679bb", "resource": { "resourceType": "Encounter", "id": "ae04a71d-a2d1-adb4-a039-c9f4d24679bb", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:2a8fcd23-149e-be1a-2570-ce377cb63986", "resource": { "resourceType": "Procedure", "id": "2a8fcd23-149e-be1a-2570-ce377cb63986", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:ae04a71d-a2d1-adb4-a039-c9f4d24679bb" }, "performedPeriod": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:44:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:9bc82a90-9c85-3ebf-adf2-241e567e9085", "resource": { "resourceType": "Procedure", "id": "9bc82a90-9c85-3ebf-adf2-241e567e9085", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:ae04a71d-a2d1-adb4-a039-c9f4d24679bb" }, "performedPeriod": { "start": "2019-12-01T02:33:36-07:00", "end": "2019-12-01T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:a6c1b6ef-a402-99b9-3069-1b74d48e65b5", "resource": { "resourceType": "Claim", "id": "a6c1b6ef-a402-99b9-3069-1b74d48e65b5", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:48:36-07:00" }, "created": "2019-11-24T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:2a8fcd23-149e-be1a-2570-ce377cb63986" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:9bc82a90-9c85-3ebf-adf2-241e567e9085" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:ae04a71d-a2d1-adb4-a039-c9f4d24679bb" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3466.85, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 1863.51, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:39f98a68-73ce-fd49-785d-b2a822b0a716", "resource": { "resourceType": "ExplanationOfBenefit", "id": "39f98a68-73ce-fd49-785d-b2a822b0a716", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "a6c1b6ef-a402-99b9-3069-1b74d48e65b5" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2019-11-24T02:48:36-07:00", "end": "2020-11-24T02:48:36-07:00" }, "created": "2019-11-24T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:a6c1b6ef-a402-99b9-3069-1b74d48e65b5" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:ae04a71d-a2d1-adb4-a039-c9f4d24679bb" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3466.85, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 693.37, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2773.48, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3466.85, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3466.85, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2019-11-24T02:33:36-07:00", "end": "2019-11-24T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 1863.51, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 372.702, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1490.808, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 1863.51, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 1863.51, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4264.2880000000009, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:777abe98-22ff-8e18-ff9d-15bb38098f91", "resource": { "resourceType": "Encounter", "id": "777abe98-22ff-8e18-ff9d-15bb38098f91", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2020-02-23T02:33:36-07:00", "end": "2020-02-23T02:48:36-07:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2020-02-23T02:33:36-07:00", "end": "2020-02-23T02:48:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:213008a6-68a2-f9c3-6336-987caf87e716", "resource": { "resourceType": "Procedure", "id": "213008a6-68a2-f9c3-6336-987caf87e716", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:777abe98-22ff-8e18-ff9d-15bb38098f91" }, "performedPeriod": { "start": "2020-02-23T02:33:36-07:00", "end": "2020-02-23T02:45:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:d9ec6096-2c36-2d99-3611-9ffbf067a104", "resource": { "resourceType": "Claim", "id": "d9ec6096-2c36-2d99-3611-9ffbf067a104", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2020-02-23T02:33:36-07:00", "end": "2020-02-23T02:48:36-07:00" }, "created": "2020-02-23T02:48:36-07:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:213008a6-68a2-f9c3-6336-987caf87e716" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:777abe98-22ff-8e18-ff9d-15bb38098f91" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2537.82, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:7b8649de-f2e7-35a3-aa74-2f3b0cd57cce", "resource": { "resourceType": "ExplanationOfBenefit", "id": "7b8649de-f2e7-35a3-aa74-2f3b0cd57cce", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "d9ec6096-2c36-2d99-3611-9ffbf067a104" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-02-23T02:48:36-07:00", "end": "2021-02-23T02:48:36-07:00" }, "created": "2020-02-23T02:48:36-07:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:d9ec6096-2c36-2d99-3611-9ffbf067a104" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2020-02-23T02:33:36-07:00", "end": "2020-02-23T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:777abe98-22ff-8e18-ff9d-15bb38098f91" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2020-02-23T02:33:36-07:00", "end": "2020-02-23T02:48:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2537.82, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 507.5640000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2030.2560000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2537.82, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2537.82, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 2030.2560000000004, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda", "resource": { "resourceType": "Encounter", "id": "3406913b-2278-87e4-9d19-0b221b998cda", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "185345009", "display": "Encounter for symptom (procedure)" } ], "text": "Encounter for symptom (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "individual": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } } ], "period": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "serviceProvider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:faa493be-56f7-3fe1-22ef-a9b49fa8c7ac", "resource": { "resourceType": "Condition", "id": "faa493be-56f7-3fe1-22ef-a9b49fa8c7ac", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "resolved" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "49727002", "display": "Cough (finding)" } ], "text": "Cough (finding)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "onsetDateTime": "2020-02-24T02:33:36-07:00", "abatementDateTime": "2020-03-13T04:20:36-06:00", "recordedDate": "2020-02-24T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:7657632a-4a9b-0e63-758f-60881bdc0743", "resource": { "resourceType": "Condition", "id": "7657632a-4a9b-0e63-758f-60881bdc0743", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "resolved" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "36955009", "display": "Loss of taste (finding)" } ], "text": "Loss of taste (finding)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "onsetDateTime": "2020-02-24T02:33:36-07:00", "abatementDateTime": "2020-03-13T04:20:36-06:00", "recordedDate": "2020-02-24T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:74645b7f-a74e-e17a-4d0a-86722c0d1ac3", "resource": { "resourceType": "Condition", "id": "74645b7f-a74e-e17a-4d0a-86722c0d1ac3", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "resolved" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "840544004", "display": "Suspected COVID-19" } ], "text": "Suspected COVID-19" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "onsetDateTime": "2020-02-24T02:33:36-07:00", "abatementDateTime": "2020-02-24T03:20:36-07:00", "recordedDate": "2020-02-24T02:33:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:32c8fdda-63cd-88c5-a765-7c813dc0ce53", "resource": { "resourceType": "Condition", "id": "32c8fdda-63cd-88c5-a765-7c813dc0ce53", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "resolved" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "840539006", "display": "COVID-19" } ], "text": "COVID-19" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "onsetDateTime": "2020-02-24T03:20:36-07:00", "abatementDateTime": "2020-03-13T04:20:36-06:00", "recordedDate": "2020-02-24T03:20:36-07:00" }, "request": { "method": "POST", "url": "Condition" } }, { "fullUrl": "urn:uuid:c1e72478-6b2d-d9f1-29c0-d22d438f0d48", "resource": { "resourceType": "Observation", "id": "c1e72478-6b2d-d9f1-29c0-d22d438f0d48", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8310-5", "display": "Body temperature" }, { "system": "http://loinc.org", "code": "8331-1", "display": "Oral temperature" } ], "text": "Body temperature" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:33:36-07:00", "issued": "2020-02-24T02:33:36.965-07:00", "valueQuantity": { "value": 38.648, "unit": "Cel", "system": "http://unitsofmeasure.org", "code": "Cel" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a7b7e417-616e-197e-9c84-f8cedde88283", "resource": { "resourceType": "Observation", "id": "a7b7e417-616e-197e-9c84-f8cedde88283", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:33:36-07:00", "issued": "2020-02-24T02:33:36.965-07:00", "valueQuantity": { "value": 38.488, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5e3aae88-8a46-abc9-25d1-3a5373eb5b16", "resource": { "resourceType": "Observation", "id": "5e3aae88-8a46-abc9-25d1-3a5373eb5b16", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:33:36-07:00", "issued": "2020-02-24T02:33:36.965-07:00", "valueQuantity": { "value": 170.43, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b41b8a81-9588-5246-6b56-e72c7def0f2d", "resource": { "resourceType": "Observation", "id": "b41b8a81-9588-5246-6b56-e72c7def0f2d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2708-6", "display": "Oxygen saturation in Arterial blood" }, { "system": "http://loinc.org", "code": "59408-5", "display": "Oxygen saturation in Arterial blood by Pulse oximetry" } ], "text": "Oxygen saturation in Arterial blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:33:36-07:00", "issued": "2020-02-24T02:33:36.965-07:00", "valueQuantity": { "value": 75.81, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:0ae474af-4dca-790c-79e4-ef87db89552b", "resource": { "resourceType": "Observation", "id": "0ae474af-4dca-790c-79e4-ef87db89552b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:33:36-07:00", "issued": "2020-02-24T02:33:36.965-07:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 74, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 120, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c6bb3e0b-8f72-5896-7477-5bc3e64ca313", "resource": { "resourceType": "Observation", "id": "c6bb3e0b-8f72-5896-7477-5bc3e64ca313", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:33:36-07:00", "issued": "2020-02-24T02:33:36.965-07:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:71ee7b76-3f63-efc7-91e1-58221ba2e229", "resource": { "resourceType": "Observation", "id": "71ee7b76-3f63-efc7-91e1-58221ba2e229", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92142-9", "display": "Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:5fa95a7f-2e3a-1a2e-be5f-c7b8a92d38d8", "resource": { "resourceType": "Observation", "id": "5fa95a7f-2e3a-1a2e-be5f-c7b8a92d38d8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92141-1", "display": "Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:564f6f81-6ef3-468b-68cd-92abfa3c0ed6", "resource": { "resourceType": "Observation", "id": "564f6f81-6ef3-468b-68cd-92abfa3c0ed6", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92131-2", "display": "Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a87ed0f4-ead4-9192-2912-239e1880af85", "resource": { "resourceType": "Observation", "id": "a87ed0f4-ead4-9192-2912-239e1880af85", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92140-3", "display": "Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:64c81405-301d-48ee-49f5-c865684c2e9c", "resource": { "resourceType": "Observation", "id": "64c81405-301d-48ee-49f5-c865684c2e9c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92139-5", "display": "Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:fd10fe5f-2a41-1a88-0b0e-e9fd07c57306", "resource": { "resourceType": "Observation", "id": "fd10fe5f-2a41-1a88-0b0e-e9fd07c57306", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92138-7", "display": "Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:2090014a-b0ff-7408-1336-4fbe0aba8c0a", "resource": { "resourceType": "Observation", "id": "2090014a-b0ff-7408-1336-4fbe0aba8c0a", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92130-4", "display": "Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:fb9bd1ff-7c12-d69b-e81f-e1d0804fb4ab", "resource": { "resourceType": "Observation", "id": "fb9bd1ff-7c12-d69b-e81f-e1d0804fb4ab", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92134-6", "display": "Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b86bb330-e39b-22f7-e798-9edfd710a950", "resource": { "resourceType": "Observation", "id": "b86bb330-e39b-22f7-e798-9edfd710a950", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "94040-3", "display": "Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection" } ], "text": "Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative (qualifier value)" } ], "text": "Negative (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d89a43ee-0612-219b-b9c1-b90be50f33a8", "resource": { "resourceType": "Observation", "id": "d89a43ee-0612-219b-b9c1-b90be50f33a8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "94531-1", "display": "SARS-CoV-2 RNA Pnl Resp NAA+probe" } ], "text": "SARS-CoV-2 RNA Pnl Resp NAA+probe" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T03:20:36-07:00", "issued": "2020-02-24T03:20:36.965-07:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260373001", "display": "Detected (qualifier value)" } ], "text": "Detected (qualifier value)" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ca05e7aa-13c9-cb5b-3cac-0e23cf0410c7", "resource": { "resourceType": "Procedure", "id": "ca05e7aa-13c9-cb5b-3cac-0e23cf0410c7", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "261352009", "display": "Face mask (physical object)" } ], "text": "Face mask (physical object)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "performedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T02:46:36-07:00" }, "reasonReference": [ { "reference": "urn:uuid:74645b7f-a74e-e17a-4d0a-86722c0d1ac3", "display": "Suspected COVID-19" } ] }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:3fc71b97-01e8-161b-b036-6f12e1159594", "resource": { "resourceType": "Procedure", "id": "3fc71b97-01e8-161b-b036-6f12e1159594", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "261352009", "display": "Face mask (physical object)" } ], "text": "Face mask (physical object)" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "performedPeriod": { "start": "2020-03-01T02:33:36-07:00", "end": "2020-03-01T02:48:36-07:00" }, "reasonReference": [ { "reference": "urn:uuid:74645b7f-a74e-e17a-4d0a-86722c0d1ac3", "display": "Suspected COVID-19" } ] }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:3aa64d39-2bcc-49da-5044-6a986839b567", "resource": { "resourceType": "Procedure", "id": "3aa64d39-2bcc-49da-5044-6a986839b567", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "performedPeriod": { "start": "2020-03-01T02:33:36-07:00", "end": "2020-03-01T02:48:36-07:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:0100063a-1e06-21f2-6a8a-8f3ce25f4eee", "resource": { "resourceType": "DiagnosticReport", "id": "0100063a-1e06-21f2-6a8a-8f3ce25f4eee", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "92143-7", "display": "Respiratory pathogens DNA and RNA panel - Respiratory specimen by NAA with probe detection" } ], "text": "Respiratory pathogens DNA and RNA panel - Respiratory specimen by NAA with probe detection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T02:46:36-07:00", "issued": "2020-02-24T02:46:36.965-07:00", "result": [ { "reference": "urn:uuid:71ee7b76-3f63-efc7-91e1-58221ba2e229", "display": "Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:5fa95a7f-2e3a-1a2e-be5f-c7b8a92d38d8", "display": "Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:564f6f81-6ef3-468b-68cd-92abfa3c0ed6", "display": "Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:a87ed0f4-ead4-9192-2912-239e1880af85", "display": "Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:64c81405-301d-48ee-49f5-c865684c2e9c", "display": "Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:fd10fe5f-2a41-1a88-0b0e-e9fd07c57306", "display": "Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:2090014a-b0ff-7408-1336-4fbe0aba8c0a", "display": "Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:fb9bd1ff-7c12-d69b-e81f-e1d0804fb4ab", "display": "Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection" }, { "reference": "urn:uuid:b86bb330-e39b-22f7-e798-9edfd710a950", "display": "Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:559f817a-19c7-3e9d-5f88-5880b7e4e350", "resource": { "resourceType": "DiagnosticReport", "id": "559f817a-19c7-3e9d-5f88-5880b7e4e350", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "94531-1", "display": "SARS-CoV-2 RNA Pnl Resp NAA+probe" } ], "text": "SARS-CoV-2 RNA Pnl Resp NAA+probe" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "effectiveDateTime": "2020-02-24T03:20:36-07:00", "issued": "2020-02-24T03:20:36.965-07:00", "result": [ { "reference": "urn:uuid:d89a43ee-0612-219b-b9c1-b90be50f33a8", "display": "SARS-CoV-2 RNA Pnl Resp NAA+probe" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:2504fd69-c73b-aabb-6317-3b56d0a11b93", "resource": { "resourceType": "CareTeam", "id": "2504fd69-c73b-aabb-6317-3b56d0a11b93", "status": "inactive", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "period": { "start": "2020-02-24T02:46:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "participant": [ { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "116154003", "display": "Patient" } ], "text": "Patient" } ], "member": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "223366009", "display": "Healthcare professional (occupation)" } ], "text": "Healthcare professional (occupation)" } ], "member": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "224891009", "display": "Healthcare services (qualifier value)" } ], "text": "Healthcare services (qualifier value)" } ], "member": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } } ], "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "840544004", "display": "Suspected COVID-19" } ], "text": "Suspected COVID-19" } ], "managingOrganization": [ { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } ] }, "request": { "method": "POST", "url": "CareTeam" } }, { "fullUrl": "urn:uuid:520e5f9a-00be-79d1-6b79-85d30c23c042", "resource": { "resourceType": "CarePlan", "id": "520e5f9a-00be-79d1-6b79-85d30c23c042", "text": { "status": "generated", "div": "
Care Plan for Infectious disease care plan (record artifact).
Activities:
Care plan is meant to treat Suspected COVID-19.
" }, "status": "completed", "intent": "order", "category": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "736376001", "display": "Infectious disease care plan (record artifact)" } ], "text": "Infectious disease care plan (record artifact)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "period": { "start": "2020-02-24T02:46:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "careTeam": [ { "reference": "urn:uuid:2504fd69-c73b-aabb-6317-3b56d0a11b93" } ], "addresses": [ { "reference": "urn:uuid:74645b7f-a74e-e17a-4d0a-86722c0d1ac3" } ], "activity": [ { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "409524006", "display": "Airborne precautions (procedure)" } ], "text": "Airborne precautions (procedure)" }, "status": "completed", "location": { "display": "SAINT ANNE'S HOSPITAL" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "409526008", "display": "Personal protective equipment (physical object)" } ], "text": "Personal protective equipment (physical object)" }, "status": "completed", "location": { "display": "SAINT ANNE'S HOSPITAL" } } } ] }, "request": { "method": "POST", "url": "CarePlan" } }, { "fullUrl": "urn:uuid:cb4dfd8e-dcab-c254-b54b-0622261c0749", "resource": { "resourceType": "CareTeam", "id": "cb4dfd8e-dcab-c254-b54b-0622261c0749", "status": "inactive", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "period": { "start": "2020-02-24T03:20:36-07:00", "end": "2020-03-13T04:20:36-06:00" }, "participant": [ { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "116154003", "display": "Patient" } ], "text": "Patient" } ], "member": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "223366009", "display": "Healthcare professional (occupation)" } ], "text": "Healthcare professional (occupation)" } ], "member": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033", "display": "Dr. Carl856 Halvorson124" } }, { "role": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "224891009", "display": "Healthcare services (qualifier value)" } ], "text": "Healthcare services (qualifier value)" } ], "member": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } } ], "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "840539006", "display": "COVID-19" } ], "text": "COVID-19" } ], "managingOrganization": [ { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" } ] }, "request": { "method": "POST", "url": "CareTeam" } }, { "fullUrl": "urn:uuid:3ac49ed9-dfe1-7828-f260-acbb373b5c24", "resource": { "resourceType": "CarePlan", "id": "3ac49ed9-dfe1-7828-f260-acbb373b5c24", "text": { "status": "generated", "div": "
Care Plan for Infectious disease care plan (record artifact).
Activities:
Care plan is meant to treat COVID-19.
" }, "status": "completed", "intent": "order", "category": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "736376001", "display": "Infectious disease care plan (record artifact)" } ], "text": "Infectious disease care plan (record artifact)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" }, "period": { "start": "2020-02-24T03:20:36-07:00", "end": "2020-03-13T04:20:36-06:00" }, "careTeam": [ { "reference": "urn:uuid:cb4dfd8e-dcab-c254-b54b-0622261c0749" } ], "addresses": [ { "reference": "urn:uuid:32c8fdda-63cd-88c5-a765-7c813dc0ce53" } ], "activity": [ { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "409524006", "display": "Airborne precautions (procedure)" } ], "text": "Airborne precautions (procedure)" }, "status": "completed", "location": { "display": "SAINT ANNE'S HOSPITAL" } } }, { "detail": { "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "361235007", "display": "Isolation of infected patient (procedure)" } ], "text": "Isolation of infected patient (procedure)" }, "status": "completed", "location": { "display": "SAINT ANNE'S HOSPITAL" } } } ] }, "request": { "method": "POST", "url": "CarePlan" } }, { "fullUrl": "urn:uuid:70c39dd3-8eba-0638-f478-c10f233aef55", "resource": { "resourceType": "Claim", "id": "70c39dd3-8eba-0638-f478-c10f233aef55", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "created": "2020-02-24T03:20:36-07:00", "provider": { "reference": "urn:uuid:ecc51621-0af3-3b35-ac3e-8b1e34022e92", "display": "SAINT ANNE'S HOSPITAL" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:faa493be-56f7-3fe1-22ef-a9b49fa8c7ac" } }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:7657632a-4a9b-0e63-758f-60881bdc0743" } }, { "sequence": 3, "diagnosisReference": { "reference": "urn:uuid:74645b7f-a74e-e17a-4d0a-86722c0d1ac3" } }, { "sequence": 4, "diagnosisReference": { "reference": "urn:uuid:32c8fdda-63cd-88c5-a765-7c813dc0ce53" } } ], "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:ca05e7aa-13c9-cb5b-3cac-0e23cf0410c7" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:3fc71b97-01e8-161b-b036-6f12e1159594" } }, { "sequence": 3, "procedureReference": { "reference": "urn:uuid:3aa64d39-2bcc-49da-5044-6a986839b567" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185345009", "display": "Encounter for symptom (procedure)" } ], "text": "Encounter for symptom (procedure)" }, "encounter": [ { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "49727002", "display": "Cough (finding)" } ], "text": "Cough (finding)" } }, { "sequence": 3, "diagnosisSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "36955009", "display": "Loss of taste (finding)" } ], "text": "Loss of taste (finding)" } }, { "sequence": 4, "diagnosisSequence": [ 3 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "840544004", "display": "Suspected COVID-19" } ], "text": "Suspected COVID-19" } }, { "sequence": 5, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "261352009", "display": "Face mask (physical object)" } ], "text": "Face mask (physical object)" }, "net": { "value": 516.65, "currency": "USD" } }, { "sequence": 6, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "261352009", "display": "Face mask (physical object)" } ], "text": "Face mask (physical object)" }, "net": { "value": 516.65, "currency": "USD" } }, { "sequence": 7, "diagnosisSequence": [ 4 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "840539006", "display": "COVID-19" } ], "text": "COVID-19" } }, { "sequence": 8, "procedureSequence": [ 3 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2734.38, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:c8c76616-7315-5180-49d2-8f7b609cedcc", "resource": { "resourceType": "ExplanationOfBenefit", "id": "c8c76616-7315-5180-49d2-8f7b609cedcc", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "performer": [ { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "70c39dd3-8eba-0638-f478-c10f233aef55" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-02-24T03:20:36-07:00", "end": "2021-02-24T03:20:36-07:00" }, "created": "2020-02-24T03:20:36-07:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:70c39dd3-8eba-0638-f478-c10f233aef55" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:07cce90b-45bb-3dde-b4a9-b98d846d6033" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "diagnosis": [ { "sequence": 1, "diagnosisReference": { "reference": "urn:uuid:faa493be-56f7-3fe1-22ef-a9b49fa8c7ac" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] }, { "sequence": 2, "diagnosisReference": { "reference": "urn:uuid:7657632a-4a9b-0e63-758f-60881bdc0743" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] }, { "sequence": 3, "diagnosisReference": { "reference": "urn:uuid:74645b7f-a74e-e17a-4d0a-86722c0d1ac3" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] }, { "sequence": 4, "diagnosisReference": { "reference": "urn:uuid:32c8fdda-63cd-88c5-a765-7c813dc0ce53" }, "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype", "code": "principal" } ] } ] } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "185345009", "display": "Encounter for symptom (procedure)" } ], "text": "Encounter for symptom (procedure)" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:3406913b-2278-87e4-9d19-0b221b998cda" } ] }, { "sequence": 2, "diagnosisSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "49727002", "display": "Cough (finding)" } ], "text": "Cough (finding)" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] } }, { "sequence": 3, "diagnosisSequence": [ 2 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "36955009", "display": "Loss of taste (finding)" } ], "text": "Loss of taste (finding)" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] } }, { "sequence": 4, "diagnosisSequence": [ 3 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "840544004", "display": "Suspected COVID-19" } ], "text": "Suspected COVID-19" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] } }, { "sequence": 5, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "261352009", "display": "Face mask (physical object)" } ], "text": "Face mask (physical object)" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 516.65, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 103.33, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 413.32, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 516.65, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 516.65, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 6, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "261352009", "display": "Face mask (physical object)" } ], "text": "Face mask (physical object)" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 516.65, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 103.33, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 413.32, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 516.65, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 516.65, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 7, "diagnosisSequence": [ 4 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "840539006", "display": "COVID-19" } ], "text": "COVID-19" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] } }, { "sequence": 8, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2020-02-24T02:33:36-07:00", "end": "2020-02-24T03:20:36-07:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2734.38, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 546.8760000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2187.5040000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2734.38, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2734.38, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 3014.1440000000004, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:65024692-b7f5-1d6c-c795-512521156a93", "resource": { "resourceType": "Encounter", "id": "65024692-b7f5-1d6c-c795-512521156a93", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2020-03-28T03:33:36-06:00", "end": "2020-03-28T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2020-03-28T03:33:36-06:00", "end": "2020-03-28T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:27e9cbf7-6da0-f605-3c99-f2b50292bb3c", "resource": { "resourceType": "Claim", "id": "27e9cbf7-6da0-f605-3c99-f2b50292bb3c", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2020-03-28T03:33:36-06:00", "end": "2020-03-28T03:48:36-06:00" }, "created": "2020-03-28T03:48:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "encounter": [ { "reference": "urn:uuid:65024692-b7f5-1d6c-c795-512521156a93" } ] } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:b04524fd-0a4b-1b54-6441-7196dfa6f71f", "resource": { "resourceType": "ExplanationOfBenefit", "id": "b04524fd-0a4b-1b54-6441-7196dfa6f71f", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "27e9cbf7-6da0-f605-3c99-f2b50292bb3c" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-03-28T03:48:36-06:00", "end": "2021-03-28T03:48:36-06:00" }, "created": "2020-03-28T03:48:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:27e9cbf7-6da0-f605-3c99-f2b50292bb3c" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "698314001", "display": "Consultation for treatment" } ], "text": "Consultation for treatment" }, "servicedPeriod": { "start": "2020-03-28T03:33:36-06:00", "end": "2020-03-28T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:65024692-b7f5-1d6c-c795-512521156a93" } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 0.0, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:1ac9ec24-c0fa-1b04-a324-9eca82d863a2", "resource": { "resourceType": "Encounter", "id": "1ac9ec24-c0fa-1b04-a324-9eca82d863a2", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:634f58a2-9b3f-e046-d07c-baf89ed5e0b9", "resource": { "resourceType": "Procedure", "id": "634f58a2-9b3f-e046-d07c-baf89ed5e0b9", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:1ac9ec24-c0fa-1b04-a324-9eca82d863a2" }, "performedPeriod": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:ae4f0a99-d477-5df4-8771-3fc7c0e719b0", "resource": { "resourceType": "Procedure", "id": "ae4f0a99-d477-5df4-8771-3fc7c0e719b0", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:1ac9ec24-c0fa-1b04-a324-9eca82d863a2" }, "performedPeriod": { "start": "2020-04-05T03:33:36-06:00", "end": "2020-04-05T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:3b29e688-c530-36f9-1168-6a6e8a287e28", "resource": { "resourceType": "Claim", "id": "3b29e688-c530-36f9-1168-6a6e8a287e28", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" }, "created": "2020-03-31T04:19:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:634f58a2-9b3f-e046-d07c-baf89ed5e0b9" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:ae4f0a99-d477-5df4-8771-3fc7c0e719b0" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:1ac9ec24-c0fa-1b04-a324-9eca82d863a2" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "net": { "value": 16242.34, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "net": { "value": 8674.66, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:ac1ab404-e602-08ef-763d-5b8b669f475e", "resource": { "resourceType": "ExplanationOfBenefit", "id": "ac1ab404-e602-08ef-763d-5b8b669f475e", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "3b29e688-c530-36f9-1168-6a6e8a287e28" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-03-31T04:19:36-06:00", "end": "2021-03-31T04:19:36-06:00" }, "created": "2020-03-31T04:19:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:3b29e688-c530-36f9-1168-6a6e8a287e28" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:1ac9ec24-c0fa-1b04-a324-9eca82d863a2" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "servicedPeriod": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 16242.34, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 3248.4680000000005, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 12993.872000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 16242.34, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 16242.34, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "65200003", "display": "Insertion of intrauterine contraceptive device" } ], "text": "Insertion of intrauterine contraceptive device" }, "servicedPeriod": { "start": "2020-03-31T03:33:36-06:00", "end": "2020-03-31T04:19:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 8674.66, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 1734.932, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 6939.728, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 8674.66, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 8674.66, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 19933.600000000002, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3", "resource": { "resourceType": "Encounter", "id": "c92773a8-7877-3d09-aa17-e032a7320db3", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "individual": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" } } ], "period": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:32fda048-c559-8332-87cf-38488956b268", "resource": { "resourceType": "Observation", "id": "32fda048-c559-8332-87cf-38488956b268", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8302-2", "display": "Body Height" } ], "text": "Body Height" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 167.7, "unit": "cm", "system": "http://unitsofmeasure.org", "code": "cm" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:60b4cf6c-87a8-5b76-3b82-6e128d0ea1a8", "resource": { "resourceType": "Observation", "id": "60b4cf6c-87a8-5b76-3b82-6e128d0ea1a8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72514-3", "display": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" } ], "text": "Pain severity - 0-10 verbal numeric rating [Score] - Reported" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 4, "unit": "{score}", "system": "http://unitsofmeasure.org", "code": "{score}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:333664fb-9d24-51a1-b8a6-1308fbd6b0cb", "resource": { "resourceType": "Observation", "id": "333664fb-9d24-51a1-b8a6-1308fbd6b0cb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "29463-7", "display": "Body Weight" } ], "text": "Body Weight" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 84.7, "unit": "kg", "system": "http://unitsofmeasure.org", "code": "kg" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c9c04e36-e6df-cf25-aa70-75efb1c01cd8", "resource": { "resourceType": "Observation", "id": "c9c04e36-e6df-cf25-aa70-75efb1c01cd8", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "39156-5", "display": "Body Mass Index" } ], "text": "Body Mass Index" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 30.12, "unit": "kg/m2", "system": "http://unitsofmeasure.org", "code": "kg/m2" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:afe3f7e8-fff0-a740-2a8a-a626d93c6d4c", "resource": { "resourceType": "Observation", "id": "afe3f7e8-fff0-a740-2a8a-a626d93c6d4c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "85354-9", "display": "Blood Pressure" } ], "text": "Blood Pressure" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "8462-4", "display": "Diastolic Blood Pressure" } ], "text": "Diastolic Blood Pressure" }, "valueQuantity": { "value": 74, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "8480-6", "display": "Systolic Blood Pressure" } ], "text": "Systolic Blood Pressure" }, "valueQuantity": { "value": 101, "unit": "mm[Hg]", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:05c1f3dc-146b-c15e-317d-d840227e3f19", "resource": { "resourceType": "Observation", "id": "05c1f3dc-146b-c15e-317d-d840227e3f19", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "8867-4", "display": "Heart rate" } ], "text": "Heart rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 97, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:aa56018e-5186-85bb-bbb9-ffd11ced3bf1", "resource": { "resourceType": "Observation", "id": "aa56018e-5186-85bb-bbb9-ffd11ced3bf1", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs", "display": "vital-signs" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9279-1", "display": "Respiratory rate" } ], "text": "Respiratory rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 13, "unit": "/min", "system": "http://unitsofmeasure.org", "code": "/min" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6cae6e24-a74f-f04c-ae8b-b28c4c4bc1c3", "resource": { "resourceType": "Observation", "id": "6cae6e24-a74f-f04c-ae8b-b28c4c4bc1c3", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2339-0", "display": "Glucose" } ], "text": "Glucose" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 91.44, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:c724ff9e-8f2d-6ddf-9f24-a88cb010fe85", "resource": { "resourceType": "Observation", "id": "c724ff9e-8f2d-6ddf-9f24-a88cb010fe85", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6299-2", "display": "Urea Nitrogen" } ], "text": "Urea Nitrogen" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 13.88, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:065edf4d-4e65-e780-4c3b-6df312628434", "resource": { "resourceType": "Observation", "id": "065edf4d-4e65-e780-4c3b-6df312628434", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "38483-4", "display": "Creatinine" } ], "text": "Creatinine" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 0.91, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:103c3781-6bc7-a01f-45fc-19b131449918", "resource": { "resourceType": "Observation", "id": "103c3781-6bc7-a01f-45fc-19b131449918", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "49765-1", "display": "Calcium" } ], "text": "Calcium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 9.98, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:4c377886-611b-c86f-614d-1da4d048c84c", "resource": { "resourceType": "Observation", "id": "4c377886-611b-c86f-614d-1da4d048c84c", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2947-0", "display": "Sodium" } ], "text": "Sodium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 137.1, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:b23f78cf-aee4-ed10-f808-83e9df76767d", "resource": { "resourceType": "Observation", "id": "b23f78cf-aee4-ed10-f808-83e9df76767d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6298-4", "display": "Potassium" } ], "text": "Potassium" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 4.49, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:6e16e473-8113-a2ef-00fb-2d6a0da17ef1", "resource": { "resourceType": "Observation", "id": "6e16e473-8113-a2ef-00fb-2d6a0da17ef1", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2069-3", "display": "Chloride" } ], "text": "Chloride" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 103.32, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:36f6afd8-c82f-15ed-ed80-e5b67d1f1ccb", "resource": { "resourceType": "Observation", "id": "36f6afd8-c82f-15ed-ed80-e5b67d1f1ccb", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "20565-8", "display": "Carbon Dioxide" } ], "text": "Carbon Dioxide" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 23.27, "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:ccd881ae-b225-5dbe-40ad-60189a09a48d", "resource": { "resourceType": "Observation", "id": "ccd881ae-b225-5dbe-40ad-60189a09a48d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2093-3", "display": "Total Cholesterol" } ], "text": "Total Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 170.73, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:89a9481f-92d1-bd13-9a5f-71e8b547d1dd", "resource": { "resourceType": "Observation", "id": "89a9481f-92d1-bd13-9a5f-71e8b547d1dd", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2571-8", "display": "Triglycerides" } ], "text": "Triglycerides" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 130.13, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:9bf36d45-bc85-2efb-a89d-1e217f94ad8b", "resource": { "resourceType": "Observation", "id": "9bf36d45-bc85-2efb-a89d-1e217f94ad8b", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "18262-6", "display": "Low Density Lipoprotein Cholesterol" } ], "text": "Low Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 82.64, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:05935edc-56bf-e686-206c-462b88114fd2", "resource": { "resourceType": "Observation", "id": "05935edc-56bf-e686-206c-462b88114fd2", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "2085-9", "display": "High Density Lipoprotein Cholesterol" } ], "text": "High Density Lipoprotein Cholesterol" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 62.07, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:83005d36-a310-a4ab-9e45-1402baba02dd", "resource": { "resourceType": "Observation", "id": "83005d36-a310-a4ab-9e45-1402baba02dd", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "14959-1", "display": "Microalbumin Creatinine Ratio" } ], "text": "Microalbumin Creatinine Ratio" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 12.69, "unit": "mg/g", "system": "http://unitsofmeasure.org", "code": "mg/g" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:e9dec576-2ff9-086b-8a78-717888ac898d", "resource": { "resourceType": "Observation", "id": "e9dec576-2ff9-086b-8a78-717888ac898d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "33914-3", "display": "Estimated Glomerular Filtration Rate" } ], "text": "Estimated Glomerular Filtration Rate" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 155.51, "unit": "mL/min/{1.73_m2}", "system": "http://unitsofmeasure.org", "code": "mL/min/{1.73_m2}" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:a7304af8-7604-3d35-d8b6-20d4eec58e79", "resource": { "resourceType": "Observation", "id": "a7304af8-7604-3d35-d8b6-20d4eec58e79", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "survey" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "72166-2", "display": "Tobacco smoking status NHIS" } ], "text": "Tobacco smoking status NHIS" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "266919005", "display": "Never smoker" } ], "text": "Never smoker" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:d1c9d40e-262f-ab8c-8883-4aa142f77f35", "resource": { "resourceType": "Observation", "id": "d1c9d40e-262f-ab8c-8883-4aa142f77f35", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "4548-4", "display": "Hemoglobin A1c/Hemoglobin.total in Blood" } ], "text": "Hemoglobin A1c/Hemoglobin.total in Blood" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "valueQuantity": { "value": 6.03, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, "request": { "method": "POST", "url": "Observation" } }, { "fullUrl": "urn:uuid:bbfdedf0-d09b-8fe6-182b-94c15e1d57d7", "resource": { "resourceType": "MedicationRequest", "id": "bbfdedf0-d09b-8fe6-182b-94c15e1d57d7", "status": "active", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "310798", "display": "Hydrochlorothiazide 25 MG Oral Tablet" } ], "text": "Hydrochlorothiazide 25 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "authoredOn": "2020-05-03T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:3ae60bf6-6973-9bd7-e1c4-16c5f33022b7", "resource": { "resourceType": "Claim", "id": "3ae60bf6-6973-9bd7-e1c4-16c5f33022b7", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "created": "2020-05-03T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:bbfdedf0-d09b-8fe6-182b-94c15e1d57d7" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:99a405fe-de5e-056f-6b78-bf8445ee3075", "resource": { "resourceType": "MedicationRequest", "id": "99a405fe-de5e-056f-6b78-bf8445ee3075", "status": "active", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "860975", "display": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" } ], "text": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "authoredOn": "2020-05-03T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:ff42a1fb-5fee-2b3b-9a78-d0ccd2883052" } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:b6d1ffe0-d66f-4c3f-5f22-75f2db1a2062", "resource": { "resourceType": "Claim", "id": "b6d1ffe0-d66f-4c3f-5f22-75f2db1a2062", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "created": "2020-05-03T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:99a405fe-de5e-056f-6b78-bf8445ee3075" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" } ] } ], "total": { "value": 291.33, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:4729ceef-5d11-7053-1f46-4a05419af659", "resource": { "resourceType": "MedicationRequest", "id": "4729ceef-5d11-7053-1f46-4a05419af659", "status": "active", "intent": "order", "medicationCodeableConcept": { "coding": [ { "system": "http://www.nlm.nih.gov/research/umls/rxnorm", "code": "314076", "display": "lisinopril 10 MG Oral Tablet" } ], "text": "lisinopril 10 MG Oral Tablet" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "authoredOn": "2020-05-03T03:33:36-06:00", "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c", "display": "Dr. Aubrey96 Boyle917" }, "reasonReference": [ { "reference": "urn:uuid:9c9b44ea-90e1-aa97-c245-db98b7aa9851" } ], "dosageInstruction": [ { "sequence": 1, "timing": { "repeat": { "frequency": 1, "period": 1.0, "periodUnit": "d" } }, "asNeededBoolean": false, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "code": "ordered", "display": "Ordered" } ] }, "doseQuantity": { "value": 1.0 } } ] } ] }, "request": { "method": "POST", "url": "MedicationRequest" } }, { "fullUrl": "urn:uuid:fb645b3c-bedd-bec3-54dc-2e109ed155b8", "resource": { "resourceType": "Claim", "id": "fb645b3c-bedd-bec3-54dc-2e109ed155b8", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "pharmacy" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "created": "2020-05-03T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "prescription": { "reference": "urn:uuid:4729ceef-5d11-7053-1f46-4a05419af659" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" } ] } ], "total": { "value": 263.49, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:9371fd68-9e3d-c277-0cd6-3754d205dca1", "resource": { "resourceType": "Immunization", "id": "9371fd68-9e3d-c277-0cd6-3754d205dca1", "status": "completed", "vaccineCode": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "occurrenceDateTime": "2020-05-03T03:33:36-06:00", "primarySource": true }, "request": { "method": "POST", "url": "Immunization" } }, { "fullUrl": "urn:uuid:44653ffa-42d5-3c78-9c17-e691ed16754d", "resource": { "resourceType": "DiagnosticReport", "id": "44653ffa-42d5-3c78-9c17-e691ed16754d", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "51990-0", "display": "Basic Metabolic Panel" } ], "text": "Basic Metabolic Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:6cae6e24-a74f-f04c-ae8b-b28c4c4bc1c3", "display": "Glucose" }, { "reference": "urn:uuid:c724ff9e-8f2d-6ddf-9f24-a88cb010fe85", "display": "Urea Nitrogen" }, { "reference": "urn:uuid:065edf4d-4e65-e780-4c3b-6df312628434", "display": "Creatinine" }, { "reference": "urn:uuid:103c3781-6bc7-a01f-45fc-19b131449918", "display": "Calcium" }, { "reference": "urn:uuid:4c377886-611b-c86f-614d-1da4d048c84c", "display": "Sodium" }, { "reference": "urn:uuid:b23f78cf-aee4-ed10-f808-83e9df76767d", "display": "Potassium" }, { "reference": "urn:uuid:6e16e473-8113-a2ef-00fb-2d6a0da17ef1", "display": "Chloride" }, { "reference": "urn:uuid:36f6afd8-c82f-15ed-ed80-e5b67d1f1ccb", "display": "Carbon Dioxide" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:9f41106b-b5d5-016b-cf73-1146f09a5933", "resource": { "resourceType": "DiagnosticReport", "id": "9f41106b-b5d5-016b-cf73-1146f09a5933", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "LAB", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57698-3", "display": "Lipid Panel" } ], "text": "Lipid Panel" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" }, "effectiveDateTime": "2020-05-03T03:33:36-06:00", "issued": "2020-05-03T03:33:36.965-06:00", "result": [ { "reference": "urn:uuid:ccd881ae-b225-5dbe-40ad-60189a09a48d", "display": "Total Cholesterol" }, { "reference": "urn:uuid:89a9481f-92d1-bd13-9a5f-71e8b547d1dd", "display": "Triglycerides" }, { "reference": "urn:uuid:9bf36d45-bc85-2efb-a89d-1e217f94ad8b", "display": "Low Density Lipoprotein Cholesterol" }, { "reference": "urn:uuid:05935edc-56bf-e686-206c-462b88114fd2", "display": "High Density Lipoprotein Cholesterol" } ] }, "request": { "method": "POST", "url": "DiagnosticReport" } }, { "fullUrl": "urn:uuid:24506d8a-d25f-ab5a-36ed-aa21eda0a262", "resource": { "resourceType": "Claim", "id": "24506d8a-d25f-ab5a-36ed-aa21eda0a262", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "created": "2020-05-03T03:48:36-06:00", "provider": { "reference": "urn:uuid:a441cbca-6d65-33ff-980c-d8e58235b7e5", "display": "PRIMA CARE PC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory", "code": "info" } ] }, "valueReference": { "reference": "urn:uuid:9371fd68-9e3d-c277-0cd6-3754d205dca1" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "Humana" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "encounter": [ { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "net": { "value": 140.52, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:981a2704-63e1-23ba-6ab7-1cb3747c0f32", "resource": { "resourceType": "ExplanationOfBenefit", "id": "981a2704-63e1-23ba-6ab7-1cb3747c0f32", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "performer": [ { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "Humana" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "Humana" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "24506d8a-d25f-ab5a-36ed-aa21eda0a262" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-05-03T03:48:36-06:00", "end": "2021-05-03T03:48:36-06:00" }, "created": "2020-05-03T03:48:36-06:00", "insurer": { "display": "Humana" }, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:24506d8a-d25f-ab5a-36ed-aa21eda0a262" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:fadfdb92-e56e-328d-b7d8-3a008e89600c" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "Humana" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "162673000", "display": "General examination of patient (procedure)" } ], "text": "General examination of patient (procedure)" }, "servicedPeriod": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:c92773a8-7877-3d09-aa17-e032a7320db3" } ] }, { "sequence": 2, "informationSequence": [ 1 ], "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://hl7.org/fhir/sid/cvx", "code": "140", "display": "Influenza, seasonal, injectable, preservative free" } ], "text": "Influenza, seasonal, injectable, preservative free" }, "servicedPeriod": { "start": "2020-05-03T03:33:36-06:00", "end": "2020-05-03T03:48:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "19", "display": "Off Campus-Outpatient Hospital" } ] }, "net": { "value": 140.52, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 28.104000000000004, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 112.41600000000001, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 140.52, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 112.41600000000001, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } }, { "fullUrl": "urn:uuid:d5188238-3ac6-49a9-1b6b-30626a14dc1b", "resource": { "resourceType": "Encounter", "id": "d5188238-3ac6-49a9-1b6b-30626a14dc1b", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB" }, "type": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" } ], "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Mrs. Antonia30 Acosta403" }, "participant": [ { "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "PPRF", "display": "primary performer" } ], "text": "primary performer" } ], "period": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" }, "individual": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f", "display": "Dr. Isreal8 Kihn564" } } ], "period": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" }, "serviceProvider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" } }, "request": { "method": "POST", "url": "Encounter" } }, { "fullUrl": "urn:uuid:bf85d852-e312-3876-66ab-a6a30163d7e4", "resource": { "resourceType": "Procedure", "id": "bf85d852-e312-3876-66ab-a6a30163d7e4", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:d5188238-3ac6-49a9-1b6b-30626a14dc1b" }, "performedPeriod": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:dc0c819c-a422-f266-d3f9-08672b4815ff", "resource": { "resourceType": "Procedure", "id": "dc0c819c-a422-f266-d3f9-08672b4815ff", "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "encounter": { "reference": "urn:uuid:d5188238-3ac6-49a9-1b6b-30626a14dc1b" }, "performedPeriod": { "start": "2020-05-31T03:33:36-06:00", "end": "2020-05-31T03:48:36-06:00" } }, "request": { "method": "POST", "url": "Procedure" } }, { "fullUrl": "urn:uuid:1839a20e-edcf-73b5-cf46-56d5761ae333", "resource": { "resourceType": "Claim", "id": "1839a20e-edcf-73b5-cf46-56d5761ae333", "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215", "display": "Antonia30 Acosta403" }, "billablePeriod": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" }, "created": "2020-05-24T03:51:36-06:00", "provider": { "reference": "urn:uuid:23834663-ed53-3da9-b330-d6e1ecb8428e", "display": "SOUTHCOAST HOSPITAL GROUP, INC" }, "priority": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/processpriority", "code": "normal" } ] }, "procedure": [ { "sequence": 1, "procedureReference": { "reference": "urn:uuid:bf85d852-e312-3876-66ab-a6a30163d7e4" } }, { "sequence": 2, "procedureReference": { "reference": "urn:uuid:dc0c819c-a422-f266-d3f9-08672b4815ff" } } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "encounter": [ { "reference": "urn:uuid:d5188238-3ac6-49a9-1b6b-30626a14dc1b" } ] }, { "sequence": 2, "procedureSequence": [ 1 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 3041.45, "currency": "USD" } }, { "sequence": 3, "procedureSequence": [ 2 ], "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "net": { "value": 2123.11, "currency": "USD" } } ], "total": { "value": 129.16, "currency": "USD" } }, "request": { "method": "POST", "url": "Claim" } }, { "fullUrl": "urn:uuid:a977ab28-e125-71db-a64a-9339167be07b", "resource": { "resourceType": "ExplanationOfBenefit", "id": "a977ab28-e125-71db-a64a-9339167be07b", "contained": [ { "resourceType": "ServiceRequest", "id": "referral", "status": "completed", "intent": "order", "subject": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "requester": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "performer": [ { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" } ] }, { "resourceType": "Coverage", "id": "coverage", "status": "active", "type": { "text": "NO_INSURANCE" }, "beneficiary": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "payor": [ { "display": "NO_INSURANCE" } ] } ], "identifier": [ { "system": "https://bluebutton.cms.gov/resources/variables/clm_id", "value": "1839a20e-edcf-73b5-cf46-56d5761ae333" }, { "system": "https://bluebutton.cms.gov/resources/identifier/claim-group", "value": "99999999999" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "institutional" } ] }, "use": "claim", "patient": { "reference": "urn:uuid:bd958c64-56b6-f206-b03d-8f4b8a417215" }, "billablePeriod": { "start": "2020-05-24T03:51:36-06:00", "end": "2021-05-24T03:51:36-06:00" }, "created": "2020-05-24T03:51:36-06:00", "insurer": { "display": "NO_INSURANCE" }, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "referral": { "reference": "#referral" }, "claim": { "reference": "urn:uuid:1839a20e-edcf-73b5-cf46-56d5761ae333" }, "outcome": "complete", "careTeam": [ { "sequence": 1, "provider": { "reference": "urn:uuid:c598151d-bd3f-3a84-8fa5-55d58f297f2f" }, "role": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "code": "primary", "display": "Primary Care Practitioner" } ] } } ], "insurance": [ { "focal": true, "coverage": { "reference": "#coverage", "display": "NO_INSURANCE" } } ], "item": [ { "sequence": 1, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "308335008", "display": "Patient encounter procedure" } ], "text": "Patient encounter procedure" }, "servicedPeriod": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "encounter": [ { "reference": "urn:uuid:d5188238-3ac6-49a9-1b6b-30626a14dc1b" } ] }, { "sequence": 2, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 3041.45, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 608.29, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 2433.16, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 3041.45, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 3041.45, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] }, { "sequence": 3, "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd", "code": "1", "display": "Medical care" } ] }, "productOrService": { "coding": [ { "system": "http://snomed.info/sct", "code": "76601001", "display": "Intramuscular injection" } ], "text": "Intramuscular injection" }, "servicedPeriod": { "start": "2020-05-24T03:33:36-06:00", "end": "2020-05-24T03:51:36-06:00" }, "locationCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace", "code": "21", "display": "Inpatient Hospital" } ] }, "net": { "value": 2123.11, "currency": "USD" }, "adjudication": [ { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt", "display": "Line Beneficiary Coinsurance Amount" } ] }, "amount": { "value": 424.62200000000009, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt", "display": "Line Provider Payment Amount" } ] }, "amount": { "value": 1698.4880000000003, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt", "display": "Line Submitted Charge Amount" } ] }, "amount": { "value": 2123.11, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt", "display": "Line Allowed Charge Amount" } ] }, "amount": { "value": 2123.11, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt", "display": "Line Beneficiary Part B Deductible Amount" } ] }, "amount": { "value": 0, "currency": "USD" } }, { "category": { "coding": [ { "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication", "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd", "display": "Line Processing Indicator Code" } ] } } ] } ], "total": [ { "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted", "display": "Submitted Amount" } ], "text": "Submitted Amount" }, "amount": { "value": 129.16, "currency": "USD" } } ], "payment": { "amount": { "value": 4131.648, "currency": "USD" } } }, "request": { "method": "POST", "url": "ExplanationOfBenefit" } } ] }