This page is part of the CARIN Blue Button Implementation Guide (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

• Narrative Content
• XML
• JSON
• TTL

: EOB Inpatient Institutional - Example 1 - XML Representation

Raw xml | Download

<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="InpatientEOBExample1"/>
  <meta>
    <lastUpdated value="2020-04-28T15:39:36-04:00"/>
    <source value="Organization/PayerOrganizationExample1"/>
    <profile
             value="http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: InpatientEOBExample1</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type institutional}">Institutional</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-ExamplePatient1.html">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; active; Member 01 Test ; Phone: 5555555551, Phone: 5555555552, Phone: 5555555553, Phone: 5555555554, Phone: 5555555555, Phone: 5555555556, GXXX@XXXX.com, Fax: 5555555557; gender: male; birthDate: 1943-01-01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}">unknown</span></a></p><p><b>billablePeriod</b>: 2017-05-23 --&gt; 2017-05-23</p><p><b>created</b>: Jun 1, 2017 4:00:00 AM</p><p><b>insurer</b>: <a href="Organization-PayerOrganizationExample1.html">UPMC Health Plan. Generated Summary: NAIC Code: 95216; active; <span title="Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}">Payer</span>; name: UPMC Health Plan; Phone: 1-844-220-4785 TTY: 711, Phone: 1-866-406-8762</a></p><p><b>provider</b>: <a href="Organization-ProviderOrganization3.html">Generated Summary: National Provider Identifier: 3334445550; active; name: Green Medical Group</a></p><h3>Payees</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td><td><b>Party</b></td></tr><tr><td>*</td><td><span title="Codes: {http://terminology.hl7.org/CodeSystem/payeetype provider}">Any benefit payable will be paid to the provider (Assignment of Benefit).</span></td><td><a href="Organization-ProviderOrganization4.html">Generated Summary: National Provider Identifier: 4445556660; active; name: Blue Medical Group</a></td></tr></table><p><b>outcome</b>: complete</p><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 1</p><p><b>provider</b>: <a href="Practitioner-Practitioner2.html">Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown </a></p><p><b>role</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole attending}">The attending physician</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href="Practitioner-Practitioner2.html">Generated Summary: National Provider Identifier: 8889990000; active; Jack Brown </a></p><p><b>role</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole referring}">The referring physician</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType billingnetworkcontractingstatus}">Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission.</span></p><p><b>code</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus contracted}">Indicates the provider was contracted for the service</span></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType clmrecvddate}">Date the claim was received by the payer.</span></p><p><b>timing</b>: 2017-06-01</p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType admissionperiod}">Dates corresponding with the admission and discharge of the beneficiary to a facility</span></p><p><b>timing</b>: 2017-05-23 --&gt; (ongoing)</p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: <span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm I21.4}">I21.4</span></p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}">The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: <span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm I25.118}">I25.118</span></p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 3</p><p><b>diagnosis</b>: <span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm E78.5}">E78.5</span></p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 4</p><p><b>diagnosis</b>: <span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm M19.90}">M19.90</span></p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType other}">Required when other conditions coexist or develop subsequently during the treatment</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 1</p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType principal}">The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title="Codes: {http://www.cms.gov/Medicare/Coding/ICD10 4A023N7}">4A023N7</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 2</p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title="Codes: {http://www.cms.gov/Medicare/Coding/ICD10 B211YZZ}">B211YZZ</span></p></blockquote><blockquote><p><b>procedure</b></p><p><b>sequence</b>: 3</p><p><b>type</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType other}">Other procedures performed during the inpatient institutional admission</span></p><p><b>date</b>: 2017-05-23</p><p><b>procedure</b>: <span title="Codes: {http://www.cms.gov/Medicare/Coding/ICD10 B215YZZ}">B215YZZ</span></p></blockquote><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-CoverageEx2.html">Generated Summary: language: en-US; An identifier for the insured of an insurance policy (this insured always has a subscriber), usually assigned by the insurance carrier.: 88800933501; status: active; subscriberId: 888009335; dependent: 01; <span title="Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span>; period: 2017-01-01 --&gt; 2017-06-30; network: GI8-HMO DEDUCTIBLE</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0301}">0301</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0260}">0260</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0305}">0305</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0324}">0324</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0259}">0259</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0250}">0250</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 7</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0710}">0710</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 8</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0210}">0210</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 9</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0272}">0272</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 10</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0370}">0370</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 11</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0730}">0730</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 12</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0450}">0450</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 13</p><p><b>revenue</b>: <span title="Codes: {http://www.nubc.org/RevenueCodes 0481}">0481</span></p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt 99231}">99231</span></p><p><b>serviced</b>: 2017-05-23 --&gt; (ongoing)</p><p><b>location</b>: <span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">HOSPITAL - INPATIENT HOSPITAL</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">The total submitted amount for the claim or group or line item.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}">Amount of the change which is considered for adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication deductible}">Amount deducted from the eligible amount prior to adjudication.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}">Patient Co-Payment</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication noncovered}">The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}">Amount payable under the coverage</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title="Codes: {http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication memberliability}">The amount of the member's liability.</span></p><h3>Amounts</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></div>
  </text>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
        <code value="uc"/>
        <display value="Unique Claim ID"/>
      </coding>
      <text
            value="Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber"/>
    </type>
    <system value="https://www.upmchealthplan.com/fhir/EOBIdentifier"/>
    <value value="InpatientEOBExample1"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
    <text value="Institutional"/>
  </type>
  <use value="claim"/>
  <patient>
    <reference value="Patient/ExamplePatient1"/>
  </patient>
  <billablePeriod>
    <start value="2017-05-23"/>
    <end value="2017-05-23"/>
  </billablePeriod>
  <created value="2017-06-01T00:00:00-04:00"/>
  <insurer>
    <reference value="Organization/PayerOrganizationExample1"/>
    <display value="UPMC Health Plan"/>
  </insurer>
  <provider>
    <reference value="Organization/ProviderOrganization3"/>
  </provider>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="provider"/>
        <display value="Provider"/>
      </coding>
      <text
            value="Any benefit payable will be paid to the provider (Assignment of Benefit)."/>
    </type>
    <party>
      <reference value="Organization/ProviderOrganization4"/>
    </party>
  </payee>
  <outcome value="complete"/>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/Practitioner2"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
        <code value="attending"/>
        <display value="Attending"/>
      </coding>
      <text value="The attending physician"/>
    </role>
  </careTeam>
  <careTeam>
    <sequence value="2"/>
    <provider>
      <reference value="Practitioner/Practitioner2"/>
    </provider>
    <role>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole"/>
        <code value="referring"/>
        <display value="Referring"/>
      </coding>
      <text value="The referring physician"/>
    </role>
  </careTeam>
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="billingnetworkcontractingstatus"/>
        <display value="Billing Network Contracting Status"/>
      </coding>
      <text
            value="Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission."/>
    </category>
    <code>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus"/>
        <code value="contracted"/>
        <display value="Contracted"/>
      </coding>
      <text value="Indicates the provider was contracted for the service"/>
    </code>
  </supportingInfo>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="clmrecvddate"/>
        <display value="Claim Received Date"/>
      </coding>
      <text value="Date the claim was received by the payer."/>
    </category>
    <timingDate value="2017-06-01"/>
  </supportingInfo>
  <supportingInfo>
    <sequence value="3"/>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
        <code value="admissionperiod"/>
        <display value="Admission Period"/>
      </coding>
      <text
            value="Dates corresponding with the admission and discharge of the beneficiary to a facility"/>
    </category>
    <timingPeriod>
      <start value="2017-05-23"/>
    </timingPeriod>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="I21.4"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
        <code value="principal"/>
        <display value="Principal Diagnosis"/>
      </coding>
      <text
            value="The single medical diagnosis that is most relevant to the patient&#39;s chief complaint or need for treatment."/>
    </type>
  </diagnosis>
  <diagnosis>
    <sequence value="2"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="I25.118"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Required when other conditions coexist or develop subsequently during the treatment"/>
    </type>
  </diagnosis>
  <diagnosis>
    <sequence value="3"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="E78.5"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Required when other conditions coexist or develop subsequently during the treatment"/>
    </type>
  </diagnosis>
  <diagnosis>
    <sequence value="4"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="M19.90"/>
      </coding>
    </diagnosisCodeableConcept>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Required when other conditions coexist or develop subsequently during the treatment"/>
    </type>
  </diagnosis>
  <procedure>
    <sequence value="1"/>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
        <code value="principal"/>
        <display value="Principal"/>
      </coding>
      <text
            value="The Principal Procedure is based on the relation of the procedure to the Principal Diagnosis"/>
    </type>
    <date value="2017-05-23"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
        <code value="4A023N7"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <procedure>
    <sequence value="2"/>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Other procedures performed during the inpatient institutional admission"/>
    </type>
    <date value="2017-05-23"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
        <code value="B211YZZ"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <procedure>
    <sequence value="3"/>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimProcedureType"/>
        <code value="other"/>
        <display value="Other"/>
      </coding>
      <text
            value="Other procedures performed during the inpatient institutional admission"/>
    </type>
    <date value="2017-05-23"/>
    <procedureCodeableConcept>
      <coding>
        <system value="http://www.cms.gov/Medicare/Coding/ICD10"/>
        <code value="B215YZZ"/>
      </coding>
    </procedureCodeableConcept>
  </procedure>
  <insurance>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/CoverageEx2"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0301"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="386.5"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="2"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0260"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="322.4"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="3"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0305"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="104.2"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="4"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0324"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="171.6"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="5"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0259"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="381.8"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="6"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0250"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="54.2"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="7"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0710"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="642.8"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="8"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0210"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="1258.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="120.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="1542.01"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="1393.57"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="9"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0272"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="303.4"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="10"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0370"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="222.8"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="11"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0730"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="33.9"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="12"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0450"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="592.4"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="13"/>
    <revenue>
      <coding>
        <system value="http://www.nubc.org/RevenueCodes"/>
        <code value="0481"/>
      </coding>
    </revenue>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="99231"/>
      </coding>
    </productOrService>
    <servicedPeriod>
      <start value="2017-05-23"/>
    </servicedPeriod>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="21"/>
      </coding>
      <text value="HOSPITAL - INPATIENT HOSPITAL"/>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
          <display value="Submitted Amount"/>
        </coding>
        <text
              value="The total submitted amount for the claim or group or line item."/>
      </category>
      <amount>
        <value value="2673.2"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="copay"/>
          <display value="CoPay"/>
        </coding>
        <text value="Patient Co-Payment"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="eligible"/>
          <display value="Eligible Amount"/>
        </coding>
        <text value="Amount of the change which is considered for adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text
              value="Amount deducted from the eligible amount prior to adjudication."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="benefit"/>
          <display value="Benefit Amount"/>
        </coding>
        <text value="Amount payable under the coverage"/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
          <code value="noncovered"/>
          <display value="Noncovered"/>
        </coding>
        <text
              value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
      </category>
      <amount>
        <value value="0.0"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="noncovered"/>
        <display value="Noncovered"/>
      </coding>
      <text
            value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
    </category>
    <amount>
      <value value="0.0"/>
      <currency value="USD"/>
    </amount>
  </adjudication>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
      <text
            value="The total submitted amount for the claim or group or line item."/>
    </category>
    <amount>
      <value value="7147.2"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="eligible"/>
        <display value="Eligible Amount"/>
      </coding>
      <text value="Amount of the change which is considered for adjudication."/>
    </category>
    <amount>
      <value value="1542.01"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="deductible"/>
        <display value="Deductible"/>
      </coding>
      <text
            value="Amount deducted from the eligible amount prior to adjudication."/>
    </category>
    <amount>
      <value value="0.0"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="copay"/>
        <display value="CoPay"/>
      </coding>
      <text value="Patient Co-Payment"/>
    </category>
    <amount>
      <value value="120.0"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="noncovered"/>
        <display value="Noncovered"/>
      </coding>
      <text
            value="The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
    </category>
    <amount>
      <value value="0.0"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="benefit"/>
        <display value="Benefit Amount"/>
      </coding>
      <text value="Amount payable under the coverage"/>
    </category>
    <amount>
      <value value="1393.57"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
        <code value="memberliability"/>
        <display value="Member liability"/>
      </coding>
      <text value="The amount of the member&#39;s liability."/>
    </category>
    <amount>
      <value value="0.0"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>