Sample data tpl

template.yaml

- resourceType: Patient
  id: ::uuid
  address:
  - city: Flushing
    line:
    - '144-11 SANFORD AVENUE #6K'
    state: NY
    district: QUEENS
    postalCode: '11355'
  meta:
    source: https://www.villagecare.org/Enrollment
  name:
  - given:
    - DEMO
    family: USER
  birthDate: '1982-07-21'
  extension:
  - url: https://www.villagecare.org/lineOfBusiness
    extension:
    - url: lineOfBusiness
      valueString: MAP
    - url: effectiveDate
      valueDate: '2020-08-01'
  active: true
  communication:
  - language:
      coding:
      - code: zh
        system: urn:ietf:bcp:47
        display: Chinese
    preferred: true
  identifier:
  - type:
      coding:
      - code: MB
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: MEMBER_ID
    value: '123456789'
    system: https://www.villagecare.org/
  - type:
      coding:
      - code: CIN
        system: https://www.villagecare.org
        display: Corporate Identification Number
    value: Q1234567
    system: https://www.villagecare.org/
  - type:
      coding:
      - code: MR
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: MEDICAL_RECORD_NUMBER
    value: 9P03NG3DT99
    system: https://www.villagecare.org/
  - type:
      coding:
      - code: SS
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: Social Security Number
    value: '123456789'
    system: https://www.villagecare.org/
  telecom:
  - use: home
    value: '1234567890'
    system: phone
  generalPractitioner:
  - id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
    resourceType: Practitioner
  - display: Edward Cho RN
  gender: female
- resourceType: Role
  id: ::uuid
  name: patient
  user:
    resourceType: User
    id: ::User.id
  links:
    patient:
      resourceType: Patient
      id: ::Patient.id
- resourceType: Organization
  id: VillageCare
  active: true
  name: VillageCare
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
    profile:
    - http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization
  type:
  - coding:
    - code: ins
      system: http://terminology.hl7.org/CodeSystem/organization-type
      display: Insurance Company
- resourceType: Practitioner
  id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
  meta:
    source: https://www.villagecare.org/Provider_Directory
    profile:
    - http://hl7.org/fhir/us/davinci-pdex-plan-net/StructureDefinition/plannet-Practitioner
  name:
  - given:
    - MANSUR
    - G
    family: ZACK
  birthDate: '1982-08-12'
  extension:
  - url: https://www.abms.org/verify-certification/
    valueCodeableConcept:
      coding:
      - code: '3'
        system: https://www.abms.org/verify-certification/
        display: Board Certified
  active: true
  communication:
  - coding:
    - code: en
      system: urn:ietf:bcp:47
      display: English
  identifier:
  - type:
      coding:
      - code: NPI
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: NPI
    value: '1234567891'
    system: http://hl7.org/fhir/sid/us-npi
  - type:
      coding:
      - code: IRS
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: IRS
    value: '12345679'
    system: http://hl7.org/fhir/sid/us-tin
  - type:
      coding:
      - code: Provid
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: PROVIDER_ID
    value: '123456789012'
    system: http://hl7.org/fhir/sid/provider-id
  - type:
      coding:
      - code: MIN
        system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
        display: Medicaid Number
    value: '12345678'
    system: http://hl7.org/fhir/sid/provider-id
  - type:
      coding:
      - code: MC
        system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
        display: Medicare ID
    value: XX12345678
    system: http://hl7.org/fhir/sid/provider-id
  qualification:
  - code:
      coding:
      - code: '6001'
        system: PSPECLTY
        display: INTERNAL MEDICINE
  - code:
      coding:
      - code: MD
        system: http://terminology.hl7.org/CodeSystem/v2-0360
        display: MEDICAL DOCTOR; DOCTOR OF MEDICINE
  telecom:
  - value: [email protected]
    system: email
  gender: male
- resourceType: Organization
  id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
  address:
  - city: FLUSHING
    line:
    - 4135 KISSENA BLVD
    type: physical
    state: NY
    district: QUEENS
    postalCode: 11355-3127
  meta:
    source: https://www.villagecare.org/Pharmacy
    profile:
    - http://hl7.org/fhir/us/davinci-pdex-plan-net/StructureDefinition/plannet-Organization
  name: DEMO PHARMACY
  type:
  - coding:
    - code: PHARMACY
      system: http://terminology.hl7.org/CodeSystem/organization-type
      display: PHARMACY
  extension:
  - url: http://hl7.org/fhir/us/davinci-pdex-plan-net/StructureDefinition/qualification
    extension:
    - url: code
      valueCodeableConcept:
        text: National Association of Boards of Pharmacy ID
    - url: status
      valueCode: active
  - url: http://hl7.org/fhir/us/davinci-pdex-plan-net/StructureDefinition/qualification
    extension:
    - url: code
      valueCodeableConcept:
        coding:
        - code: '76001'
          system: PSPECLTY
          display: PHARMACY
    - url: status
      valueCode: active
  active: true
  identifier:
  - type:
      coding:
      - code: NPI
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: NPI
    value: '1234567890'
    system: http://hl7.org/fhir/sid/us-npi
  - type:
      coding:
      - code: NABP
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: NABP
    value: '1234567'
    system: http://hl7.org/fhir/sid/us-nabp
  - type:
      coding:
      - code: TAX
        system: http://terminology.hl7.org/CodeSystem/v2-0203
        display: TAX
    value: '123456789'
    system: http://hl7.org/fhir/sid/us-tax
  telecom:
  - value: '123456789'
    system: phone
  - value: [email protected]
    system: email
  - value: '111'
    system: phone
- resourceType: Medication
  id: ace5be32-42b4-465e-8519-dbd0a18399ae
  code:
    coding:
    - code: '00186504031'
      system: https://ndclist.com/ndc
      display: NEXIUM DR 40 MG CAPSULE
  form:
    coding:
    - code: CE
      display: CAPSULE DR
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
  status: inactive
- resourceType: Medication
  id: 5608a0de-851f-4368-af88-dd390c2bf3e3
  code:
    coding:
    - code: '00597015330'
      system: https://ndclist.com/ndc
      display: JARDIANCE 25 MG TABLET
  form:
    coding:
    - code: TA
      display: TABLET
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
  status: inactive
- resourceType: Coverage
  id: ::uuid
  policyHolder:
    id: VillageCare
    resourceType: Organization
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
    profile:
    - http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage
  beneficiary:
    id: ::Patient.id
    resourceType: Patient
  relationship:
    coding:
    - code: other
      system: http://terminology.hl7.org/CodeSystem/subscriber-relationship
      display: Other
  type:
    coding:
    - code: HIP
      system: http://terminology.hl7.org/CodeSystem/v3-ActCode
      display: health insurance plan policy
  subscriber:
    id: ::Patient.id
    resourceType: Patient
  payor:
  - id: VillageCare
    resourceType: Organization
  status: active
  class:
  - name: MAP
    type:
      text: Group to which the member is associated
      coding:
      - code: group
        system: http://terminology.hl7.org/CodeSystem/coverage-class
        display: Group
    value: H1234567
  - type:
      text: Identifies the Plan
      coding:
      - code: plan
        system: http://terminology.hl7.org/CodeSystem/coverage-class
        display: Plan
    value: H1234
  - type:
      text: Identifies the specific PBP within a contract
      coding:
      - code: subplan
        system: http://terminology.hl7.org/CodeSystem/coverage-class
        display: SubPlan
    value: '002'
  - name: VILLAGECAREMAX - HMO SNP
    type:
      text: A class of benefits
      coding:
      - code: class
        system: http://terminology.hl7.org/CodeSystem/coverage-class
        display: Class
    value: VCM02
  network: AA7777R
  period:
    end: '2030-12-31'
    start: '2021-07-05'
  subscriberId: '123456789'
- resourceType: Coverage
  id: ::uuid
  policyHolder:
    id: VillageCare
    resourceType: Organization
  meta:
    source: https://www.villagecare.org/ILS_Claim
    profile:
      - http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage
  beneficiary:
    id: ::Patient.id
    resourceType: Patient
  relationship:
    coding:
      - code: self
        system: http://terminology.hl7.org/CodeSystem/subscriber-relationship
        display: Self
  type:
    coding:
      - code: HIP
        system: http://terminology.hl7.org/CodeSystem/v3-ActCode
        display: health insurance plan policy
  subscriber:
    id: ::Patient.id
    resourceType: Patient
  payor:
    - id: VillageCare
      resourceType: Organization
  status: cancelled
  class:
    - name: MCD
      type:
        text: Group to which the member is associated
        coding:
          - code: group
            system: http://terminology.hl7.org/CodeSystem/coverage-class
            display: Group
      value: '101'
    - type:
        text: Identifies the Plan
        coding:
          - code: plan
            system: http://terminology.hl7.org/CodeSystem/coverage-class
            display: Plan
      value: '101'
    - type:
        text: A class of benefits
        coding:
          - code: class
            system: http://terminology.hl7.org/CodeSystem/coverage-class
            display: Class
      value: '10'
    - name: MCD 18 AND OVER
      type:
        text: A policy type
        coding:
          - code: type
            system: http://terminology.hl7.org/CodeSystem/coverage-class
            display: Type
      value: '78'
  identifier:
    - type:
        coding:
          - code: COV
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Coverage ID
      value: '123456789987654321'
      system: https://www.villagecare.org/
  network: DEFAULT IPA
  period:
    end: '2016-09-25'
    start: '2015-06-03'
  dependent: '01'
  subscriberId: '12345678912'
- resourceType: MedicationRequest
  id: ::uuid
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
  authoredOn: '2022-01-05'
  requester:
    id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
    resourceType: Practitioner
  status: completed
  dosageInstruction:
    - timing: {}
      doseAndRate:
        - dose:
            Quantity:
              value: 30
  identifier:
    - type:
        coding:
          - code: PRESCRIPTION_NUMBER
            system: http://terminology.hl7.org/CodeSystem/v2-0203
            display: PRESCRIPTION_NUMBER
      value: '000000467050'
  intent: plan
  subject:
    id: ::Patient.id
    resourceType: Patient
  medication:
    Reference:
      id: ace5be32-42b4-465e-8519-dbd0a18399ae
      resourceType: Medication
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.0.id
        resourceType: Coverage
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy
  supportingInfo:
    - value:
        Quantity:
          code: d
          unit: day
          value: 30
      category:
        coding:
          - code: dayssupply
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Days Supply
      sequence: 1
    - code:
        coding:
          - code: '1'
            system: >-
              http://terminology.hl7.org/CodeSystem/NCPDP/DispensedAsWrittenOrProductSelectionCode
            display: Physician DAW
      category:
        coding:
          - code: dawcode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: DAW (Dispense As Written) Code
      sequence: 2
    - value:
        Quantity:
          value: 0
      category:
        coding:
          - code: refillnum
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Refill NumberW
      sequence: 3
    - code:
        coding:
          - code: contracted
            system: >-
              http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
            display: Contracted
      category:
        coding:
          - code: billingnetworkcontractingstatus
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Billing Network Contracting Status
      sequence: 4
    - code:
        coding:
          - code: '2'
            system: http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator
            display: Brand
      category:
        coding:
          - code: brandgenericcode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Brand Generic Code
      sequence: 5
    - code:
        coding:
          - code: '3'
            system: http://terminology.hl7.org/CodeSystem/NCPDP/PrescriptionOriginCode
            display: Electronic
      category:
        coding:
          - code: rxorigincode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Rx Origin Code
      sequence: 6
    - code:
        coding:
          - code: '1'
            system: http://terminology.hl7.org/CodeSystem/NCPDP/CompoundCode
            display: Non-compound
      category:
        coding:
          - code: compoundcode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Compound Code
      sequence: 7
  use: claim
  item:
    - sequence: 1
      serviced:
        Period:
          end: '2022-02-10'
          start: '2022-02-10'
      adjudication:
        - amount:
            value: 330.36
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
      productOrService:
        coding:
          - code: '00186504031'
            system: http://hl7.org/fhir/sid/ndc
            display: NEXIUM DR 40 MG CAPSULE
  type:
    coding:
      - code: pharmacy
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2022-01-10'
  outcome: complete
  total:
    - amount:
        value: 341.36
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 103.8
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 103.8
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: priorpayerpaid
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Prior payer paid
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: paidbypatient
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid by patient
    - amount:
        value: 103.8
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
    - amount:
        value: 103.8
        currency: USD
      category:
        coding:
          - code: drugcost
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Drug cost
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: memberliability
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Member liability
    - amount:
        value: 103.8
        currency: USD
      category:
        coding:
          - code: innetwork
            system: >-
              http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
            display: In Network
          - code: inoutnetwork
            system: >-
              http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
            display: In or Out of Network
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  prescription:
    id: ::MedicationRequest.0.id
    resourceType: MedicationRequest
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '1000000001'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: prescribing
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole
            display: Prescribing provider
      provider:
        id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
        resourceType: Practitioner
      sequence: 1
- resourceType: MedicationRequest
  id: ::uuid
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
  authoredOn: '2021-04-08'
  requester:
    id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
    resourceType: Practitioner
  status: completed
  dosageInstruction:
    - timing: {}
      doseAndRate:
        - dose:
            Quantity:
              value: 30
  identifier:
    - type:
        coding:
          - code: PRESCRIPTION_NUMBER
            system: http://terminology.hl7.org/CodeSystem/v2-0203
            display: PRESCRIPTION_NUMBER
      value: '000000630725'
  intent: plan
  subject:
    id: ::Patient.id
    resourceType: Patient
  medication:
    Reference:
      id: 5608a0de-851f-4368-af88-dd390c2bf3e3
      resourceType: Medication
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.1.id
        resourceType: Coverage
  meta:
    source: https://www.villagecare.org/Pharmacy_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy
  supportingInfo:
    - value:
        Quantity:
          code: d
          unit: day
          value: 30
      category:
        coding:
          - code: dayssupply
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Days Supply
      sequence: 1
    - code:
        coding:
          - code: '0'
            system: >-
              http://terminology.hl7.org/CodeSystem/NCPDP/DispensedAsWrittenOrProductSelectionCode
            display: No DAW
      category:
        coding:
          - code: dawcode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: DAW (Dispense As Written) Code
      sequence: 2
    - value:
        Quantity:
          value: 1
      category:
        coding:
          - code: refillnum
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Refill NumberW
      sequence: 3
    - code:
        coding:
          - code: contracted
            system: >-
              http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
            display: Contracted
      category:
        coding:
          - code: billingnetworkcontractingstatus
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Billing Network Contracting Status
      sequence: 4
    - code:
        coding:
          - code: '2'
            system: http://terminology.hl7.org/CodeSystem/NCPDP/BrandGenericIndicator
            display: Brand
      category:
        coding:
          - code: brandgenericcode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Brand Generic Code
      sequence: 5
    - code:
        coding:
          - code: '3'
            system: http://terminology.hl7.org/CodeSystem/NCPDP/PrescriptionOriginCode
            display: Electronic
      category:
        coding:
          - code: rxorigincode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Rx Origin Code
      sequence: 6
    - code:
        coding:
          - code: '1'
            system: http://terminology.hl7.org/CodeSystem/NCPDP/CompoundCode
            display: Non-compound
      category:
        coding:
          - code: compoundcode
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Compound Code
      sequence: 7
  use: claim
  item:
    - sequence: 1
      serviced:
        Period:
          end: '2021-06-12'
          start: '2021-06-12'
      adjudication:
        - amount:
            value: 659.7
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
      productOrService:
        coding:
          - code: '00597015330'
            system: http://hl7.org/fhir/sid/ndc
            display: JARDIANCE 25 MG TABLET
  type:
    coding:
      - code: pharmacy
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2021-06-12'
  outcome: complete
  total:
    - amount:
        value: 671.4
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 542.12
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 542.12
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: priorpayerpaid
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Prior payer paid
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: paidbypatient
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid by patient
    - amount:
        value: 542.12
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
    - amount:
        value: 542.12
        currency: USD
      category:
        coding:
          - code: drugcost
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Drug cost
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: memberliability
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Member liability
    - amount:
        value: 542.12
        currency: USD
      category:
        coding:
          - code: innetwork
            system: >-
              http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
            display: In Network
          - code: inoutnetwork
            system: >-
              http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
            display: In or Out of Network
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  prescription:
    id: ::MedicationRequest.1.id
    resourceType: MedicationRequest
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '1000000002'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: prescribing
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole
            display: Prescribing provider
      provider:
        id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
        resourceType: Practitioner
      sequence: 1
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.0.id
        resourceType: Coverage
  diagnosis:
    - type:
        - coding:
            - code: principal
              system: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
              display: Principal Diagnosis
      sequence: 1
      diagnosis:
        CodeableConcept:
          coding:
            - code: '25000'
              system: http://terminology.hl7.org/CodeSystem/icd9
    - type:
        - coding:
            - code: other
              system: >-
                http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType
              display: Other
      sequence: 2
      diagnosis:
        CodeableConcept:
          coding:
            - code: '3693'
              system: http://terminology.hl7.org/CodeSystem/icd9
    - type:
        - coding:
            - code: other
              system: >-
                http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType
              display: Other
      sequence: 3
      diagnosis:
        CodeableConcept:
          coding:
            - code: '4019'
              system: http://terminology.hl7.org/CodeSystem/icd9
  meta:
    source: https://www.villagecare.org/ILS_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional
  use: claim
  item:
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 1
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 2
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 3
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 4
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 5
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 6
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 153.2
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 7
      serviced:
        date: '2016-07-18'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 132.82
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 132.82
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 132.82
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
  type:
    coding:
      - code: institutional
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2016-07-18'
  outcome: complete
  extension:
    - url: https://www.villagecare.org/
      valueCodeableConcept:
        coding:
          - code: S
            system: https://www.villagecare.org/PAY_FLAG
            display: Claim paid by System
  total:
    - amount:
        value: 1025.8
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 1025.8
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 1025.8
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: noncovered
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Noncovered
    - amount:
        value: 1025.8
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '100000000000001'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: primary
            system: http://terminology.hl7.org/CodeSystem/claimcareteamrole
            display: Primary provider
      provider:
        id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
        resourceType: Organization
      sequence: 1
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.0.id
        resourceType: Coverage
  diagnosis:
    - type:
        - coding:
            - code: principal
              system: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
              display: Principal Diagnosis
      sequence: 1
      diagnosis:
        CodeableConcept:
          coding:
            - code: '43822'
              system: http://terminology.hl7.org/CodeSystem/icd9
  meta:
    source: https://www.villagecare.org/ILS_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician
  use: claim
  item:
    - category:
        coding:
          - code: '0000000005'
            system: TOSCODE
            display: DME/PROSTHETICS/ORTHOTICS/SUPPLIES
      sequence: 1
      serviced:
        Period:
          end: '2015-08-01'
          start: '2015-08-01'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '3'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED ACCORDING TO FEE SCHEDULE
      adjudication:
        - amount:
            value: 82.42
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 82.42
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 82.42
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 82.42
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T4521
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Adult sized disposable incontinence product, brief/diaper, small,
              each
      diagnosisSequence:
        - 1
  type:
    coding:
      - code: professional
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2015-08-11'
  outcome: complete
  extension:
    - url: https://www.villagecare.org/
      valueCodeableConcept:
        coding:
          - code: S
            system: https://www.villagecare.org/PAY_FLAG
            display: Claim paid by System
  total:
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        value: 82.42
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 82.42
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 82.42
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: noncovered
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Noncovered
    - amount:
        value: 82.42
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '100000000000002'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: primary
            system: http://terminology.hl7.org/CodeSystem/claimcareteamrole
            display: Primary provider
      provider:
        id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
        resourceType: Organization
      sequence: 1
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.1.id
        resourceType: Coverage
  diagnosis:
    - type:
        - coding:
            - code: principal
              system: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
              display: Principal Diagnosis
      sequence: 1
      diagnosis:
        CodeableConcept:
          coding:
            - code: '43820'
              system: http://terminology.hl7.org/CodeSystem/icd9
  meta:
    source: https://www.villagecare.org/ILS_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician
  use: claim
  item:
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 1
      serviced:
        Period:
          end: '2015-08-08'
          start: '2015-08-08'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence:
        - 1
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 2
      serviced:
        Period:
          end: '2015-08-09'
          start: '2015-08-09'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
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        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence:
        - 1
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 3
      serviced:
        Period:
          end: '2015-08-10'
          start: '2015-08-10'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 253
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence:
        - 1
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 4
      serviced:
        Period:
          end: '2015-08-12'
          start: '2015-08-12'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence:
        - 1
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 5
      serviced:
        Period:
          end: '2015-08-13'
          start: '2015-08-13'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence:
        - 1
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 6
      serviced:
        Period:
          end: '2015-08-14'
          start: '2015-08-14'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
        - amount:
            value: 231
            currency: USD
          category:
            coding:
              - code: innetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
                display: In Network
              - code: inoutnetwork
                system: >-
                  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
                display: In or Out of Network
      productOrService:
        coding:
          - code: T1019
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per 15 minutes, not for an inpatient or
              resident of a hospital, nursing facility, ICF/MR or IMD, part of
              the individualized plan of treatment (code may not be used to
              identify services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence:
        - 1
  type:
    coding:
      - code: professional
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2015-08-25'
  outcome: complete
  extension:
    - url: https://www.villagecare.org/
      valueCodeableConcept:
        coding:
          - code: S
            system: https://www.villagecare.org/PAY_FLAG
            display: Claim paid by System
  total:
    - amount:
        value: 1412
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 1412
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 1412
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: noncovered
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Noncovered
    - amount:
        value: 1412
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '100000000000003'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: primary
            system: http://terminology.hl7.org/CodeSystem/claimcareteamrole
            display: Primary provider
      provider:
        id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
        resourceType: Organization
      sequence: 1
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.1.id
        resourceType: Coverage
  diagnosis:
    - type:
        - coding:
            - code: principal
              system: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
              display: Principal Diagnosis
      sequence: 1
      diagnosis:
        CodeableConcept:
          coding:
            - code: '2900'
              system: http://terminology.hl7.org/CodeSystem/icd9
  meta:
    source: https://www.villagecare.org/ILS_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional
  use: claim
  item:
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 1
      serviced:
        date: '2015-05-29'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 235
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: -17.85999999999999
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 2
      serviced:
        date: '2015-05-30'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 235
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: -17.85999999999999
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 3
      serviced:
        date: '2015-05-31'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 235
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: -17.85999999999999
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 4
      serviced:
        date: '2015-06-05'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 235
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: -17.85999999999999
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 5
      serviced:
        date: '2015-06-06'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 235
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: -17.85999999999999
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
    - category:
        coding:
          - code: '0000000004'
            system: TOSCODE
            display: PERSONAL CARE
      sequence: 6
      serviced:
        date: '2015-06-07'
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 235
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: copay
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: CoPay
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: eligible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Eligible Amount
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: deductible
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Deductible
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: coinsurance
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Coinsurance
        - amount:
            value: -17.85999999999999
            currency: USD
          category:
            coding:
              - code: noncovered
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Noncovered
        - amount:
            value: 239.85
            currency: USD
          category:
            coding:
              - code: paidtoprovider
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Paid to provider
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: discount
                system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
                display: Discount
      productOrService:
        coding:
          - code: T1020
            system: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
            display: >-
              Personal care services, per diem, not for an inpatient or resident
              of a hospital, nursing facility, ICF/MR or IMD, part of the
              individualized plan of treatment (code may not be used to identify
              services provided by home health aide or certified nurse
              assistant)
      diagnosisSequence: []
  type:
    coding:
      - code: institutional
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2015-06-12'
  outcome: complete
  extension:
    - url: https://www.villagecare.org/
      valueCodeableConcept:
        coding:
          - code: S
            system: https://www.villagecare.org/PAY_FLAG
            display: Claim paid by System
  total:
    - amount:
        value: 1332
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 1444.56
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 1444.56
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: -112.55999999999995
        currency: USD
      category:
        coding:
          - code: noncovered
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Noncovered
    - amount:
        value: 1444.56
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '100000000000004'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: primary
            system: http://terminology.hl7.org/CodeSystem/claimcareteamrole
            display: Primary provider
      provider:
        id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
        resourceType: Organization
      sequence: 1
- resourceType: ExplanationOfBenefit
  id: ::uuid
  patient:
    id: ::Patient.id
    resourceType: Patient
  insurance:
    - focal: true
      coverage:
        id: ::Coverage.1.id
        resourceType: Coverage
  diagnosis:
    - type:
        - coding:
            - code: principal
              system: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
              display: Principal Diagnosis
      sequence: 1
      diagnosis:
        CodeableConcept:
          coding:
            - code: B20
              system: http://hl7.org/fhir/sid/icd-10-cm
              display: Human immunodeficiency virus [HIV] disease
    - type:
        - coding:
            - code: admitting
              system: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
              display: Admitting Diagnosis
      sequence: 2
      diagnosis:
        CodeableConcept:
          coding:
            - code: B20
              system: http://hl7.org/fhir/sid/icd-10-cm
              display: Human immunodeficiency virus [HIV] disease
    - type:
        - coding:
            - code: other
              system: >-
                http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType
              display: Other
      sequence: 3
      diagnosis:
        CodeableConcept:
          coding:
            - code: I11.0
              system: http://hl7.org/fhir/sid/icd-10-cm
              display: Hypertensive heart disease with heart failure
    - type:
        - coding:
            - code: other
              system: >-
                http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimDiagnosisType
              display: Other
      sequence: 4
      diagnosis:
        CodeableConcept:
          coding:
            - code: E08.9
              system: http://hl7.org/fhir/sid/icd-10-cm
              display: >-
                Diabetes mellitus due to underlying condition without
                complications
  meta:
    source: https://www.villagecare.org/ILS_Claim
    profile:
      - >-
        http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional
  supportingInfo:
    - timing:
        Period:
          end: '2020-12-03'
          start: '2020-11-10'
      category:
        coding:
          - code: admissionperiod
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
            display: Admission Period
      sequence: 1
  use: claim
  item:
    - revenue:
        coding:
          - code: '0120'
            system: http://www.nubc.org/RevenueCodes
            display: Room & Board-Semiprivate (Two-Beds)-General
      category:
        coding:
          - code: '0000000037'
            system: TOSCODE
            display: NURSING FACILITY
      sequence: 1
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 850
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
      productOrService:
        coding:
          - code: '0120'
            system: http://www.ama-assn.org/go/cpt
    - revenue:
        coding:
          - code: '0022'
            system: http://www.nubc.org/RevenueCodes
            display: Skilled nursing facility prospective payment system (HIPPS)
      category:
        coding:
          - code: '0000000037'
            system: TOSCODE
            display: NURSING FACILITY
      sequence: 2
      extension:
        - url: https://www.villagecare.org/
          valueCodeableConcept:
            coding:
              - code: '9'
                system: https://www.villagecare.org/PAY_CODE
                display: PRICED PER CONTRACTED RATE
      adjudication:
        - amount:
            value: 0
            currency: USD
          category:
            coding:
              - code: submitted
                system: http://terminology.hl7.org/CodeSystem/adjudication
                display: Submitted Amount
      productOrService:
        coding:
          - code: '0022'
            system: http://www.ama-assn.org/go/cpt
  type:
    coding:
      - code: institutional
        system: http://terminology.hl7.org/CodeSystem/claim-type
  created: '2021-03-02'
  outcome: complete
  extension:
    - url: https://www.villagecare.org/
      valueCodeableConcept:
        coding:
          - code: S
            system: https://www.villagecare.org/PAY_FLAG
            display: Claim paid by System
  total:
    - amount:
        value: 850
        currency: USD
      category:
        coding:
          - code: submitted
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Submitted Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: copay
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: CoPay
    - amount:
        value: 655.92
        currency: USD
      category:
        coding:
          - code: eligible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Eligible Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: deductible
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Deductible
    - amount:
        value: 40
        currency: USD
      category:
        coding:
          - code: benefit
            system: http://terminology.hl7.org/CodeSystem/adjudication
            display: Benefit Amount
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: coinsurance
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Coinsurance
    - amount:
        value: 194.08000000000004
        currency: USD
      category:
        coding:
          - code: noncovered
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Noncovered
    - amount:
        value: 0
        currency: USD
      category:
        coding:
          - code: priorpayerpaid
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Prior payer paid
    - amount:
        value: 40
        currency: USD
      category:
        coding:
          - code: paidtoprovider
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
            display: Paid to provider
  insurer:
    id: VillageCare
    resourceType: Organization
  status: active
  billablePeriod:
    end: '2020-12-03'
    start: '2020-11-10'
  identifier:
    - type:
        coding:
          - code: uc
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
            display: Unique Claim ID
      value: '100000000000005'
      system: https://www.villagecare.org/
  provider:
    id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
    resourceType: Organization
  careTeam:
    - role:
        coding:
          - code: primary
            system: http://terminology.hl7.org/CodeSystem/claimcareteamrole
            display: Primary provider
      provider:
        id: 15c1c3d9-3d5c-43eb-b479-a279f58233a3
        resourceType: Organization
      sequence: 1
    - role:
        coding:
          - code: attending
            system: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole
            display: The attending physician
      provider:
        id: 2b06bf69-36eb-42da-84a8-0defc3f3a3c6
        resourceType: Practitioner
      sequence: 2