CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 US

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: EOB Professional - Example 2 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "EOBProfessional2"];
  fhir:Resource.meta [
     fhir:Meta.lastUpdated [ fhir:value "2020-10-20T14:46:05-04:00"^^xsd:dateTime ];
     fhir:Meta.source [ fhir:value "Organization/PayerOrganizationExample1" ];
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.0.0";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|2.0.0>     ]
  ];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"EOBProfessional2\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ExplanationOfBenefit &quot;EOBProfessional2&quot; Updated &quot;2020-10-20 02:46:05-0400&quot; </p><p style=\"margin-bottom: 0px\">Information Source: Organization/PayerOrganizationExample1!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-C4BB-ExplanationOfBenefit-Professional-NonClinician.html\">C4BB ExplanationOfBenefit Professional NonClinician (version 2.0.0)</a></p></div><p><b>identifier</b>: Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber: ProfessionalEOBExample1</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href=\"Patient-Patient1.html\">Patient/Patient1</a> &quot; EXAMPLE1&quot;</p><p><b>billablePeriod</b>: 2020-08-04 --&gt; 2020-08-04</p><p><b>created</b>: 2020-08-24 12:00:00-0400</p><p><b>insurer</b>: <a href=\"Organization-Payer2.html\">Organization/Payer2: UPMC Health Plan</a> &quot;UPMC Health Plan&quot;</p><p><b>provider</b>: <a href=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1</a> &quot;Orange Medical Group&quot;</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>Any benefit payable will be paid to the provider (Assignment of Benefit). <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-payeetype.html\">Claim Payee Type Codes</a>#provider &quot;Provider&quot;)</span></td><td><a href=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1</a> &quot;Orange Medical Group&quot;</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=\"Organization-ProviderOrganization1.html\">Organization/ProviderOrganization1</a> &quot;Orange Medical Group&quot;</p><p><b>role</b>: The primary care provider. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-claimcareteamrole.html\">Claim Care Team Role Codes</a>#primary &quot;Primary provider&quot;)</span></p></blockquote><blockquote><p><b>careTeam</b></p><p><b>sequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-Practitioner1.html\">Practitioner/Practitioner1</a> &quot; SMITH&quot;</p><p><b>role</b>: The referring physician <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimCareTeamRole.html\">C4BB Claim Care Team Role Code System</a>#referring &quot;Referring&quot;)</span></p></blockquote><h3>SupportingInfos</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Timing[x]</b></td></tr><tr><td>*</td><td>1</td><td>Date the claim was received by the payer. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBSupportingInfoType.html\">C4BB Supporting Info Type Code System</a>#clmrecvddate &quot;Claim Received Date&quot;)</span></td><td>2020-08-24</td></tr></table><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 1</p><p><b>diagnosis</b>: Athscl native arteries of left leg w ulceration of unsp site <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#I70.249)</span></p><p><b>type</b>: The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal &quot;Principal Diagnosis&quot;)</span></p></blockquote><blockquote><p><b>diagnosis</b></p><p><b>sequence</b>: 2</p><p><b>diagnosis</b>: Non-prs chronic ulc unsp prt of l low leg w unsp severity <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#L97.929)</span></p><p><b>type</b>: Required when necessary to report additional diagnoses on professional and non-clinician claims <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBClaimDiagnosisType.html\">C4BB Claim Diagnosis Type Code System</a>#secondary &quot;secondary&quot;)</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-Coverage1.html\">Coverage/Coverage1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: 75710 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#75710)</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>68.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>34.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>34.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: 75710 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#75710)</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>-68.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>-34.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>-34.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: 75710 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#75710)</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>68.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>34.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>34.8</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 4</p><p><b>productOrService</b>: 37228 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#37228)</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>751.2</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>224.11</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>224.11</td><td>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 5</p><p><b>productOrService</b>: 37228 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#37228)</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>751.2</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>224.11</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>224.11</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 6</p><p><b>productOrService</b>: 37228 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#37228)</span></p><p><b>serviced</b>: 2020-08-04</p><p><b>location</b>: HOSPITAL - INPATIENT HOSPITAL <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><blockquote><p><b>adjudication</b></p><p><b>category</b>: Benefit Payment Status <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#benefitpaymentstatus)</span></p><p><b>reason</b>: In Network <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork)</span></p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>-751.2</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>-224.11</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>-224.11</td><td>USD</td></tr></table></blockquote></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Category</b></td><td><b>Reason</b></td></tr><tr><td>*</td><td>Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudicationDiscriminator.html\">C4BB Adjudication Discriminator Code System</a>#billingnetworkstatus &quot;Billing Network Status&quot;)</span></td><td>Indicates the provider was in network for the service <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBPayerAdjudicationStatus.html\">C4BB Payer Adjudication Status Code System</a>#innetwork &quot;In Network&quot;)</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: The total submitted amount for the claim or group or line item. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted &quot;Submitted Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>820</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount of the change which is considered for adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#eligible &quot;Eligible Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>258.91</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount deducted from the eligible amount prior to adjudication. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#deductible &quot;Deductible&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Patient Co-Payment <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#copay &quot;CoPay&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: 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 style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#noncovered &quot;Noncovered&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Amount payable under the coverage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/4.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#benefit &quot;Benefit Amount&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>258.91</td><td>USD</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: The amount of the member's liability. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-C4BBAdjudication.html\">C4BB Adjudication Code System</a>#memberliability &quot;Member liability&quot;)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>0</td><td>USD</td></tr></table></blockquote></div>"
  ];
  fhir:ExplanationOfBenefit.identifier [
     fhir:index 0;
     fhir:Identifier.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType" ];
         fhir:Coding.code [ fhir:value "uc" ];
         fhir:Coding.display [ fhir:value "Unique Claim ID" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber" ]     ];
     fhir:Identifier.system [ fhir:value "https://www.upmchealthplan.com/fhir/EOBIdentifier" ];
     fhir:Identifier.value [ fhir:value "ProfessionalEOBExample1" ]
  ];
  fhir:ExplanationOfBenefit.status [ fhir:value "active"];
  fhir:ExplanationOfBenefit.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "professional" ]     ];
     fhir:CodeableConcept.text [ fhir:value "Professional" ]
  ];
  fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
  fhir:ExplanationOfBenefit.patient [
     fhir:Reference.reference [ fhir:value "Patient/Patient1" ]
  ];
  fhir:ExplanationOfBenefit.billablePeriod [
     fhir:Period.start [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:Period.end [ fhir:value "2020-08-04"^^xsd:date ]
  ];
  fhir:ExplanationOfBenefit.created [ fhir:value "2020-08-24T00:00:00-04:00"^^xsd:dateTime];
  fhir:ExplanationOfBenefit.insurer [
     fhir:Reference.reference [ fhir:value "Organization/Payer2" ];
     fhir:Reference.display [ fhir:value "UPMC Health Plan" ]
  ];
  fhir:ExplanationOfBenefit.provider [
     fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization1" ]
  ];
  fhir:ExplanationOfBenefit.payee [
     fhir:ExplanationOfBenefit.payee.type [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ];
         fhir:Coding.code [ fhir:value "provider" ];
         fhir:Coding.display [ fhir:value "Provider" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Any benefit payable will be paid to the provider (Assignment of Benefit)." ]     ];
     fhir:ExplanationOfBenefit.payee.party [
       fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization1" ]     ]
  ];
  fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"];
  fhir:ExplanationOfBenefit.careTeam [
     fhir:index 0;
     fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.careTeam.provider [
       fhir:Reference.reference [ fhir:value "Organization/ProviderOrganization1" ]     ];
     fhir:ExplanationOfBenefit.careTeam.role [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claimcareteamrole" ];
         fhir:Coding.code [ fhir:value "primary" ];
         fhir:Coding.display [ fhir:value "Primary provider" ]       ];
       fhir:CodeableConcept.text [ fhir:value "The primary care provider." ]     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.careTeam.provider [
       fhir:Reference.reference [ fhir:value "Practitioner/Practitioner1" ]     ];
     fhir:ExplanationOfBenefit.careTeam.role [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole" ];
         fhir:Coding.code [ fhir:value "referring" ];
         fhir:Coding.display [ fhir:value "Referring" ]       ];
       fhir:CodeableConcept.text [ fhir:value "The referring physician" ]     ]
  ];
  fhir:ExplanationOfBenefit.supportingInfo [
     fhir:index 0;
     fhir:ExplanationOfBenefit.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.supportingInfo.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType" ];
         fhir:Coding.code [ fhir:value "clmrecvddate" ];
         fhir:Coding.display [ fhir:value "Claim Received Date" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Date the claim was received by the payer." ]     ];
     fhir:ExplanationOfBenefit.supportingInfo.timingDate [ fhir:value "2020-08-24"^^xsd:date ]
  ];
  fhir:ExplanationOfBenefit.diagnosis [
     fhir:index 0;
     fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
         fhir:Coding.code [ fhir:value "I70.249" ]       ]     ];
     fhir:ExplanationOfBenefit.diagnosis.type [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" ];
         fhir:Coding.code [ fhir:value "principal" ];
         fhir:Coding.display [ fhir:value "Principal Diagnosis" ]       ];
       fhir:CodeableConcept.text [ fhir:value "The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment." ]     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ];
         fhir:Coding.code [ fhir:value "L97.929" ]       ]     ];
     fhir:ExplanationOfBenefit.diagnosis.type [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType" ];
         fhir:Coding.code [ fhir:value "secondary" ];
         fhir:Coding.display [ fhir:value "secondary" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Required when necessary to report additional diagnoses on professional and non-clinician claims" ]     ]
  ];
  fhir:ExplanationOfBenefit.insurance [
     fhir:index 0;
     fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ExplanationOfBenefit.insurance.coverage [
       fhir:Reference.reference [ fhir:value "Coverage/Coverage1" ]     ]
  ];
  fhir:ExplanationOfBenefit.item [
     fhir:index 0;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
         fhir:Coding.code [ fhir:value "75710" ]       ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
         fhir:Coding.code [ fhir:value "21" ]       ];
       fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
           fhir:Coding.code [ fhir:value "benefitpaymentstatus" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
           fhir:Coding.code [ fhir:value "innetwork" ]         ]       ]     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "submitted" ];
           fhir:Coding.display [ fhir:value "Submitted Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "68.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "CoPay" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 3;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "34.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 4;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "deductible" ];
           fhir:Coding.display [ fhir:value "Deductible" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 5;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "benefit" ];
           fhir:Coding.display [ fhir:value "Benefit Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "34.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 6;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
           fhir:Coding.code [ fhir:value "noncovered" ];
           fhir:Coding.display [ fhir:value "Noncovered" ]         ];
         fhir:CodeableConcept.text [ fhir: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." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "2"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
         fhir:Coding.code [ fhir:value "75710" ]       ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
         fhir:Coding.code [ fhir:value "21" ]       ];
       fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
           fhir:Coding.code [ fhir:value "benefitpaymentstatus" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
           fhir:Coding.code [ fhir:value "innetwork" ]         ]       ]     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "submitted" ];
           fhir:Coding.display [ fhir:value "Submitted Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "-68.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "CoPay" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 3;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "-34.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 4;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "deductible" ];
           fhir:Coding.display [ fhir:value "Deductible" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 5;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "benefit" ];
           fhir:Coding.display [ fhir:value "Benefit Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "-34.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 6;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
           fhir:Coding.code [ fhir:value "noncovered" ];
           fhir:Coding.display [ fhir:value "Noncovered" ]         ];
         fhir:CodeableConcept.text [ fhir: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." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ], [
     fhir:index 2;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "3"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
         fhir:Coding.code [ fhir:value "75710" ]       ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
         fhir:Coding.code [ fhir:value "21" ]       ];
       fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
           fhir:Coding.code [ fhir:value "benefitpaymentstatus" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
           fhir:Coding.code [ fhir:value "innetwork" ]         ]       ]     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "submitted" ];
           fhir:Coding.display [ fhir:value "Submitted Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "68.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "CoPay" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 3;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "34.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 4;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "deductible" ];
           fhir:Coding.display [ fhir:value "Deductible" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 5;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "benefit" ];
           fhir:Coding.display [ fhir:value "Benefit Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "34.8"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 6;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
           fhir:Coding.code [ fhir:value "noncovered" ];
           fhir:Coding.display [ fhir:value "Noncovered" ]         ];
         fhir:CodeableConcept.text [ fhir: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." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ], [
     fhir:index 3;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "4"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
         fhir:Coding.code [ fhir:value "37228" ]       ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
         fhir:Coding.code [ fhir:value "21" ]       ];
       fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
           fhir:Coding.code [ fhir:value "benefitpaymentstatus" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
           fhir:Coding.code [ fhir:value "innetwork" ]         ]       ]     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "submitted" ];
           fhir:Coding.display [ fhir:value "Submitted Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "751.2"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "CoPay" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 3;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "224.11"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 4;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "deductible" ];
           fhir:Coding.display [ fhir:value "Deductible" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 5;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "benefit" ];
           fhir:Coding.display [ fhir:value "Benefit Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 6;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
           fhir:Coding.code [ fhir:value "noncovered" ];
           fhir:Coding.display [ fhir:value "Noncovered" ]         ];
         fhir:CodeableConcept.text [ fhir: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." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "224.11"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ], [
     fhir:index 4;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "5"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
         fhir:Coding.code [ fhir:value "37228" ]       ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
         fhir:Coding.code [ fhir:value "21" ]       ];
       fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
           fhir:Coding.code [ fhir:value "benefitpaymentstatus" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
           fhir:Coding.code [ fhir:value "innetwork" ]         ]       ]     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "submitted" ];
           fhir:Coding.display [ fhir:value "Submitted Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "751.2"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "CoPay" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 3;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "224.11"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 4;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "deductible" ];
           fhir:Coding.display [ fhir:value "Deductible" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 5;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "benefit" ];
           fhir:Coding.display [ fhir:value "Benefit Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "224.11"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 6;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
           fhir:Coding.code [ fhir:value "noncovered" ];
           fhir:Coding.display [ fhir:value "Noncovered" ]         ];
         fhir:CodeableConcept.text [ fhir: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." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ], [
     fhir:index 5;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "6"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ];
         fhir:Coding.code [ fhir:value "37228" ]       ]     ];
     fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2020-08-04"^^xsd:date ];
     fhir:ExplanationOfBenefit.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ];
         fhir:Coding.code [ fhir:value "21" ]       ];
       fhir:CodeableConcept.text [ fhir:value "HOSPITAL - INPATIENT HOSPITAL" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
           fhir:Coding.code [ fhir:value "benefitpaymentstatus" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.reason [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
           fhir:Coding.code [ fhir:value "innetwork" ]         ]       ]     ], [
       fhir:index 1;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "submitted" ];
           fhir:Coding.display [ fhir:value "Submitted Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "-751.2"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 2;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "copay" ];
           fhir:Coding.display [ fhir:value "CoPay" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 3;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "eligible" ];
           fhir:Coding.display [ fhir:value "Eligible Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "-224.11"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 4;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "deductible" ];
           fhir:Coding.display [ fhir:value "Deductible" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 5;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
           fhir:Coding.code [ fhir:value "benefit" ];
           fhir:Coding.display [ fhir:value "Benefit Amount" ]         ];
         fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ], [
       fhir:index 6;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
           fhir:Coding.code [ fhir:value "noncovered" ];
           fhir:Coding.display [ fhir:value "Noncovered" ]         ];
         fhir:CodeableConcept.text [ fhir: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." ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "-224.11"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ];
  fhir:ExplanationOfBenefit.adjudication [
     fhir:index 0;
     fhir:ExplanationOfBenefit.item.adjudication.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator" ];
         fhir:Coding.code [ fhir:value "billingnetworkstatus" ];
         fhir:Coding.display [ fhir:value "Billing Network Status" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Indicates that the Billing Provider has a contract with the Payer as of the effective date of service or admission." ]     ];
     fhir:ExplanationOfBenefit.item.adjudication.reason [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus" ];
         fhir:Coding.code [ fhir:value "innetwork" ];
         fhir:Coding.display [ fhir:value "In Network" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Indicates the provider was in network for the service" ]     ]
  ];
  fhir:ExplanationOfBenefit.total [
     fhir:index 0;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
         fhir:Coding.code [ fhir:value "submitted" ];
         fhir:Coding.display [ fhir:value "Submitted Amount" ]       ];
       fhir:CodeableConcept.text [ fhir:value "The total submitted amount for the claim or group or line item." ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "820"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ], [
     fhir:index 1;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
         fhir:Coding.code [ fhir:value "eligible" ];
         fhir:Coding.display [ fhir:value "Eligible Amount" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Amount of the change which is considered for adjudication." ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "258.91"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ], [
     fhir:index 2;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
         fhir:Coding.code [ fhir:value "deductible" ];
         fhir:Coding.display [ fhir:value "Deductible" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ], [
     fhir:index 3;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
         fhir:Coding.code [ fhir:value "copay" ];
         fhir:Coding.display [ fhir:value "CoPay" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Patient Co-Payment" ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ], [
     fhir:index 4;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
         fhir:Coding.code [ fhir:value "noncovered" ];
         fhir:Coding.display [ fhir:value "Noncovered" ]       ];
       fhir:CodeableConcept.text [ fhir: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." ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ], [
     fhir:index 5;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
         fhir:Coding.code [ fhir:value "benefit" ];
         fhir:Coding.display [ fhir:value "Benefit Amount" ]       ];
       fhir:CodeableConcept.text [ fhir:value "Amount payable under the coverage" ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "258.91"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ], [
     fhir:index 6;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
         fhir:Coding.code [ fhir:value "memberliability" ];
         fhir:Coding.display [ fhir:value "Member liability" ]       ];
       fhir:CodeableConcept.text [ fhir:value "The amount of the member's liability." ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "0"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.