ExplanationOfBenefit - Medical


Full Profile Definition: Profile: Explanaton Of Benefit - Medical


Resource Content:

Differential

idΣ0..1string
id0..1string
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profileΣ0..*canonical(StructureDefinition)
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implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
claim-number1..1IdentifierPattern
statusS Σ ?!1..1codeBinding
typeS Σ1..1Element: Codeable ConceptBindingPattern
subTypeS0..1Element: Codeable ConceptBinding
useS Σ1..1codeBindingFixed Value
patientS Σ I1..1Reference(Profile: Patient)
billablePeriodS Σ I1..1Period
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entererI0..1Reference(Practitioner | PractitionerRole)
insurerS Σ I1..1Reference(Profile: Insurance Company)
providerS Σ I1..1Reference(Profile: Healthcare Organization | Profile: Practitioner)
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fundsReserve0..1CodeableConcept
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extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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prescriptionI0..1Reference(MedicationRequest | VisionPrescription)
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extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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modifierExtensionΣ ?! I0..*Extension
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id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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providerI1..1Reference(Profile: Healthcare Organization | Profile: Practitioner)
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role0..1CodeableConceptPattern
qualification0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
providerI1..1Reference(Practitioner | PractitionerRole | Organization)
responsible0..1booleanFixed Value
role0..1CodeableConceptPattern
qualification0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
providerI1..1Reference(Profile: Practitioner)
responsible0..1booleanFixed Value
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modifierExtensionΣ ?! I0..*Extension
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modifierExtensionΣ ?! I0..*Extension
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timingDatedate
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valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
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timingDatedate
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reason0..1Coding
id0..1string
extensionI0..*Extension
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timingDatedate
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reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
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timingPeriodPeriod
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reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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timingDatedate
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reason0..1Coding
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
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valueBooleanboolean
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reason0..1Coding
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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typeS0..*Element: Codeable ConceptPattern
onAdmissionS0..1Element: Codeable Concept
packageCodeS0..1Element: Codeable Concept
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequenceS1..1positiveInt
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udiI0..*Reference(Device)
precedence0..1positiveInt
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modifierExtensionΣ ?! I0..*Extension
focalS Σ1..1booleanFixed Value
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productOrServiceS1..1Element: Codeable Concept
modifierS0..*CodeableConcept
programCode0..*CodeableConcept
servicedDatedate
servicedPeriodPeriod
locationCodeableConceptCodeableConcept
locationAddressAddress
locationReferenceReference(Location)
quantityS I0..1SimpleQuantity
unitPriceS0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
bodySite0..1CodeableConcept
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encounterI0..*Reference(Encounter)
noteNumber0..*positiveInt
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extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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reason0..1CodeableConcept
amount1..1Money
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extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveInt
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productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
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net0..1Money
udiI0..*Reference(Device)
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveInt
revenue0..1CodeableConcept
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modifierExtensionΣ ?! I0..*Extension
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productOrService1..1CodeableConcept
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servicedPeriodPeriod
locationCodeableConceptCodeableConcept
locationAddressAddress
locationReferenceReference(Location)
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
bodySite0..1CodeableConcept
subSite0..*CodeableConcept
noteNumber0..*positiveInt
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id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
type0..1CodeableConcept
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adjustmentReason0..1CodeableConcept
date0..1date
amount0..1Money
identifier0..1Identifier
formCode0..1CodeableConcept
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id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
number0..1positiveInt
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text0..1string
language0..1CodeableConceptBinding
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id0..1string
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category1..1CodeableConcept
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term0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
type1..1CodeableConcept
allowedUnsignedIntunsignedInt
allowedStringstring
allowedMoneyMoney
usedUnsignedIntunsignedInt
usedMoneyMoney

Hybrid

idΣ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ1..1uri
profileΣ0..*canonical(StructureDefinition)
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
claim-number1..1IdentifierPattern
statusS Σ ?!1..1codeBinding
typeS Σ1..1Element: Codeable ConceptBindingPattern
subTypeS0..1Element: Codeable ConceptBinding
useS Σ1..1codeBindingFixed Value
patientS Σ I1..1Reference(Profile: Patient)
billablePeriodS Σ I1..1Period
createdS Σ1..1dateTime
entererI0..1Reference(Practitioner | PractitionerRole)
insurerS Σ I1..1Reference(Profile: Insurance Company)
providerS Σ I1..1Reference(Profile: Healthcare Organization | Profile: Practitioner)
priority0..1CodeableConcept
fundsReserveRequested0..1CodeableConcept
fundsReserve0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
claimI0..1Reference(Claim)
relationship0..1CodeableConcept
reference0..1Identifier
prescriptionI0..1Reference(MedicationRequest | VisionPrescription)
originalPrescriptionI0..1Reference(MedicationRequest)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
type0..1CodeableConcept
partyI0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
referralI0..1Reference(ServiceRequest)
facilityI0..1Reference(Location)
claimI0..1Reference(Claim)
claimResponseI0..1Reference(ClaimResponse)
outcomeS Σ1..1codeBinding
disposition0..1string
preAuthRef0..*string
preAuthRefPeriodI0..*Period
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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providerI1..1Reference(Practitioner | PractitionerRole | Organization)
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id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
providerI1..1Reference(Profile: Practitioner)
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role0..1CodeableConceptPattern
qualification0..1CodeableConcept
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequenceS1..1positiveInt
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code0..1CodeableConcept
timingDatedate
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valueBooleanboolean
valueStringstring
valueQuantityQuantity
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valueReferenceReference(Resource)
reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
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timingDatedate
valueBooleanboolean
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valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
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id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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timingDatedate
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reason0..1Coding
id0..1string
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modifierExtensionΣ ?! I0..*Extension
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reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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timingDatedate
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valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
category1..1CodeableConceptPattern
code1..1CodeableConceptBindingPattern
timingDatedate
timingPeriodPeriod
valueBooleanboolean
valueStringstring
valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
category1..1CodeableConceptPattern
code0..1CodeableConcept
timingPeriodPeriod
valueBooleanboolean
valueStringstring
valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1Coding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
category1..1CodeableConceptPattern
code1..1CodeableConceptPattern
timingDatedate
timingPeriodPeriod
valueBooleanboolean
valueStringstring
valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1Coding
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveIntFixed Value
category1..1CodeableConceptPattern
code1..1CodeableConceptPattern
timingDatedate
timingPeriodPeriod
valueBooleanboolean
valueStringstring
valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1Coding
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequenceS1..1positiveInt
diagnosisCodeableConceptElement: Codeable Concept
typeS0..*Element: Codeable ConceptPattern
onAdmissionS0..1Element: Codeable Concept
packageCodeS0..1Element: Codeable Concept
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequenceS1..1positiveInt
type0..*CodeableConcept
dateS1..1dateTime
procedureCodeableConceptElement: Codeable Concept
udiI0..*Reference(Device)
precedence0..1positiveInt
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
focalS Σ1..1booleanFixed Value
coverageS Σ I1..1Reference(Profile: Insurance Coverage)
preAuthRef0..*string
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
date0..1date
type0..1CodeableConceptBinding
locationAddressAddress
locationReferenceReference(Location)
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequenceS1..1positiveInt
careTeamSequence0..*positiveInt
diagnosisSequence0..*positiveInt
procedureSequence0..*positiveInt
informationSequence0..*positiveInt
revenueS0..1Element: Codeable Concept
category0..1CodeableConcept
productOrServiceS1..1Element: Codeable Concept
modifierS0..*CodeableConcept
programCode0..*CodeableConcept
servicedDatedate
servicedPeriodPeriod
locationCodeableConceptCodeableConcept
locationAddressAddress
locationReferenceReference(Location)
quantityS I0..1SimpleQuantity
unitPriceS0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
bodySite0..1CodeableConcept
subSite0..*CodeableConcept
encounterI0..*Reference(Encounter)
noteNumber0..*positiveInt
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable Concept
reason0..1CodeableConcept
amount0..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1Element: Codeable ConceptPattern
reason0..1CodeableConcept
amount1..1Money
value0..1decimal
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveInt
revenue0..1CodeableConcept
category0..1CodeableConcept
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
sequence1..1positiveInt
revenue0..1CodeableConcept
category0..1CodeableConcept
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
itemSequence0..*positiveInt
detailSequence0..*positiveInt
subDetailSequence0..*positiveInt
providerI0..*Reference(Practitioner | PractitionerRole | Organization)
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
servicedDatedate
servicedPeriodPeriod
locationCodeableConceptCodeableConcept
locationAddressAddress
locationReferenceReference(Location)
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
bodySite0..1CodeableConcept
subSite0..*CodeableConcept
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryS1..1Element: Codeable ConceptBinding
reasonS0..1CodeableConcept
amountS1..1Money
value0..1decimal
idS1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryS Σ1..1Element: Codeable ConceptBinding
amountS Σ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id1..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
categoryΣ1..1Element: Codeable ConceptPattern
amountΣ1..1Money
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
type0..1CodeableConcept
adjustment0..1Money
adjustmentReason0..1CodeableConcept
date0..1date
amount0..1Money
identifier0..1Identifier
formCode0..1CodeableConcept
formI0..1Attachment
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
number0..1positiveInt
type0..1codeBinding
text0..1string
language0..1CodeableConceptBinding
benefitPeriodS I0..1Period
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
category1..1CodeableConcept
excluded0..1boolean
name0..1string
description0..1string
network0..1CodeableConcept
unit0..1CodeableConcept
term0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
type1..1CodeableConcept
allowedUnsignedIntunsignedInt
allowedStringstring
allowedMoneyMoney
usedUnsignedIntunsignedInt
usedMoneyMoney



Examples:

{
    "resourceType": "ExplanationOfBenefit",
    "id": "example-eob-medical-professional-without-totals",
    "meta": {
        "source": "https://www.foo.com/medical_claims",
        "profile":  [
            "https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-explanation-of-benefit-medical"
        ],
        "security":  [
            {
                "system": "https://www.icanbwell.com/owner",
                "code": "foo"
            },
            {
                "system": "https://www.icanbwell.com/access",
                "code": "foo"
            }
        ]
    },
    "identifier":  [
        {
            "id": "claim-number",
            "type": {
                "coding":  [
                    {
                        "id": "type",
                        "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                        "code": "Claim_Nbr",
                        "display": "Claim Number"
                    }
                ],
                "text": "Claim Number"
            },
            "system": "https://www.foo.com",
            "value": "A111222333444555666777888999"
        }
    ],
    "status": "active",
    "type": {
        "coding":  [
            {
                "id": "type",
                "system": "http://terminology.hl7.org/CodeSystem/claim-type",
                "code": "professional"
            }
        ],
        "text": "Claim Type"
    },
    "use": "claim",
    "patient": {
        "reference": "Patient/12345"
    },
    "billablePeriod": {
        "start": "2020-01-30T00:00:00.000Z",
        "end": "2020-01-30T00:00:00.000Z"
    },
    "created": "2020-02-14T00:00:00.000Z",
    "insurer": {
        "reference": "Organization/insurance-company"
    },
    "provider": {
        "reference": "Organization/1234567890|nppes"
    },
    "outcome": "complete",
    "supportingInfo":  [
        {
            "id": "ms-drg",
            "sequence": 7,
            "category": {
                "coding":  [
                    {
                        "id": "info",
                        "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
                        "code": "info"
                    },
                    {
                        "id": "carin",
                        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
                        "code": "drg",
                        "display": "Diagnosis Related Groups Code"
                    },
                    {
                        "id": "type",
                        "system": "https://www.icanbwell.com/CodeSystem/SupportingInfoType",
                        "code": "original"
                    }
                ]
            },
            "code": {
                "coding":  [
                    {
                        "id": "code",
                        "system": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software",
                        "code": "00000"
                    }
                ]
            }
        },
        {
            "id": "8",
            "sequence": 8,
            "category": {
                "coding":  [
                    {
                        "id": "info",
                        "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
                        "code": "info"
                    },
                    {
                        "id": "info-pos",
                        "system": "http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory",
                        "code": "placeofservice",
                        "display": "Place of Service"
                    }
                ]
            },
            "code": {
                "coding":  [
                    {
                        "id": "pos",
                        "system": "https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-setsl",
                        "code": "11",
                        "display": "OFFICE"
                    }
                ]
            }
        }
    ],
    "diagnosis":  [
        {
            "id": "diagnosis-1",
            "sequence": 1,
            "diagnosisCodeableConcept": {
                "coding":  [
                    {
                        "id": "diag-code",
                        "system": "http://hl7.org/fhir/sid/icd-10-cm",
                        "version": "ICD10CM",
                        "code": "Z00.129"
                    }
                ]
            },
            "type":  [
                {
                    "id": "type",
                    "coding":  [
                        {
                            "id": "code",
                            "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
                            "code": "retrospective"
                        }
                    ]
                }
            ]
        }
    ],
    "insurance":  [
        {
            "id": "insurance",
            "focal": true,
            "coverage": {
                "reference": "Coverage/12345-01FEB2020"
            }
        }
    ],
    "item":  [
        {
            "id": "item-1",
            "sequence": 1,
            "productOrService": {
                "coding":  [
                    {
                        "id": "product",
                        "system": "http://www.nlm.nih.gov/research/umls/cpt",
                        "code": "92551",
                        "display": "SCREENING TEST PURE TONE AIR ONLY"
                    }
                ]
            },
            "servicedDate": "2020-01-30",
            "quantity": {
                "value": 1.0
            },
            "adjudication":  [
                {
                    "id": "benefit-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "benefit-category-code",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "benefit",
                                "display": "Benefit Amount"
                            }
                        ]
                    },
                    "amount": {
                        "value": 31.25
                    }
                },
                {
                    "id": "allowed-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "allowed-category-code",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "allowed",
                                "display": "Allowed Amount"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "copay-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "copay-category-code",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "copay",
                                "display": "Copay"
                            }
                        ]
                    },
                    "amount": {
                        "value": 0.0
                    }
                },
                {
                    "id": "eligible-amount",
                    "category": {
                        "coding":  [
                            {
                                "id": "eligible-category-code",
                                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                                "code": "eligible",
                                "display": "Eligible-Amount"
                            }
                        ]
                    },
                    "amount": {
                        "value": 40.82
                    }
                }
            ]
        }
    ]
}