Jarred626_Walsh511_ea6f7f29-8553-4456-8fa9-3d629ffcd5f7.json•723 kB
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"end": "2025-12-19T22:06:35+00:00"
},
"created": "2024-12-19T22:06:35+00:00",
"insurer": {
"display": "Anthem"
},
"provider": {
"reference": "urn:uuid:00000199-c8f5-3ea7-0000-0000000010b8"
},
"referral": {
"reference": "#referral"
},
"claim": {
"reference": "urn:uuid:9be5dc1e-343d-4633-9899-78f808563263"
},
"outcome": "complete",
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "urn:uuid:00000199-c8f5-3ea7-0000-0000000010b8"
},
"role": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
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}
]
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
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}
}
],
"item": [
{
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"category": {
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{
"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": "410620009",
"display": "Well child visit (procedure)"
}
],
"text": "Well child visit (procedure)"
},
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"end": "2024-12-19T22:06:35+00:00"
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"locationCodeableConcept": {
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{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
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{
"reference": "urn:uuid:e662123c-19ae-491d-b4f7-ae48bc3e55c2"
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{
"sequence": 2,
"informationSequence": [
1
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{
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]
},
"productOrService": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/cvx",
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"display": "Influenza, seasonal, injectable, preservative free"
}
],
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},
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"end": "2024-12-19T22:06:35+00:00"
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"locationCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
"code": "19",
"display": "Off Campus-Outpatient Hospital"
}
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},
"net": {
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"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": 28.104000000000003,
"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": {
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"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": {
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"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": {
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"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": {
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"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": {
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"currency": "USD"
}
}
],
"payment": {
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}
},
"request": {
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"url": "ExplanationOfBenefit"
}
}
]
}