{
  "resourceType": "ExplanationOfBenefit",
  "id": "e6c4234b-19a8-4e5c-35cb-5d05a97d5788",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional"
    ]
  },
  "related": [
    {
      "reference": {
        "value": "Q19137E17126"
      },
      "claim": {
        "reference": "ExplanationOfBenefit/EqUVAXt5WrNnlJPdB7swbxJXaYxxnvBxWwGPxUx1up"
      },
      "relationship": {
        "coding": [
          {
            "code": "prior",
            "system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"
          }
        ]
      }
    },
    {
      "reference": {
        "value": "Q19137E17126"
      },
      "claim": {
        "reference": "ExplanationOfBenefit/ABCDEXg2WrYnlJrdr7sabxZZaYffnvBxWwGPx99999"
      },
      "relationship": {
        "coding": [
          {
            "code": "replacedby",
            "system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"
          }
        ]
      }
    }
  ],
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider",
          "system": "http://terminology.hl7.org/CodeSystem/payeetype"
        }
      ]
    },
    "party": {
      "reference": "Organization/iAxXvHiphwGGAL48m3B7XXtKlLZg6yXnC1ch84x1up"
    }
  },
  "contained": [
    {
      "resourceType": "ServiceRequest",
      "id": "referral",
      "status": "completed",
      "intent": "order",
      "subject": {
        "reference": "Patient/f56391c2-dd54-b378-46ef-87c1643a2ba0"
      },
      "requester": {
        "reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
      },
      "performer": [
        {
          "reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
        }
      ]
    }
  ],
  "identifier": [
    {
      "system": "https://bluebutton.cms.gov/resources/variables/clm_id",
      "value": "c145d3fe-d56e-dc26-75e9-01e90672f506"
    },
    {
      "system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
      "value": "99999999999"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "institutional"
      }
    ]
  },
  "subType": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType",
        "code": "inpatient"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/f56391c2-dd54-b378-46ef-87c1643a2ba0"
  },
  "billablePeriod": {
    "start": "2017-01-05T21:41:04+01:00",
    "end": "2018-01-05T21:41:04+01:00"
  },
  "created": "2017-01-05T21:41:04+01:00",
  "insurer": {
    "display": "Medicaid"
  },
  "provider": {
    "reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
  },
  "referral": {
    "reference": "#referral"
  },
  "facility": {
    "reference": "Location/e111a884-fc5e-3766-9077-c44100ba56e2",
    "display": "NEWTON-WELLESLEY HOSPITAL"
  },
  "claim": {
    "reference": "Claim/c145d3fe-d56e-dc26-75e9-01e90672f506"
  },
  "outcome": "complete",
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/820ee8ba-855a-3aaf-9eeb-6603cfdaee25"
      },
      "role": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claimcareteamrole",
            "code": "primary",
            "display": "Primary Care Practitioner"
          }
        ]
      }
    }
  ],
  "supportingInfo": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
            "code": "clmrecvddate"
          }
        ]
      },
      "timingDate": "2017-01-05"
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisReference": {
        "reference": "Condition/88bd5ac6-175b-5906-a4ee-6eedd667b0cc"
      },
      "type": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code": "principal"
            }
          ]
        }
      ]
    }
  ],
  "insurance": [
    {
      "focal": true,
      "coverage": {
        "display": "Medicaid"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
            "code": "1",
            "display": "Medical care"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "185345009",
            "display": "Encounter for symptom"
          }
        ],
        "text": "Encounter for symptom"
      },
      "servicedPeriod": {
        "start": "2017-01-05T21:26:04+01:00",
        "end": "2017-01-05T21:41:04+01:00"
      },
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
            "code": "21",
            "display": "Inpatient Hospital"
          }
        ]
      },
      "encounter": [
        {
          "reference": "Encounter/97e2c68b-c5e6-02f3-867b-f9f207badd64"
        }
      ]
    },
    {
      "sequence": 2,
      "diagnosisSequence": [1],
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
            "code": "1",
            "display": "Medical care"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "10509002",
            "display": "Acute bronchitis (disorder)"
          }
        ],
        "text": "Acute bronchitis (disorder)"
      },
      "servicedPeriod": {
        "start": "2017-01-05T21:26:04+01:00",
        "end": "2017-01-05T21:41:04+01:00"
      },
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
            "code": "21",
            "display": "Inpatient Hospital"
          }
        ]
      }
    },
    {
      "sequence": 3,
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd",
            "code": "1",
            "display": "Medical care"
          }
        ]
      },
      "productOrService": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "23426006",
            "display": "Measurement of respiratory function (procedure)"
          }
        ],
        "text": "Measurement of respiratory function (procedure)"
      },
      "servicedPeriod": {
        "start": "2017-01-05T21:26:04+01:00",
        "end": "2017-01-05T21:41:04+01:00"
      },
      "locationCodeableConcept": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
            "code": "21",
            "display": "Inpatient Hospital"
          }
        ]
      },
      "net": {
        "value": 146.42,
        "currency": "USD"
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt",
                "display": "Line Beneficiary Coinsurance Amount"
              }
            ]
          },
          "amount": {
            "value": 29.284,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt",
                "display": "Line Provider Payment Amount"
              }
            ]
          },
          "amount": {
            "value": 117.136,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt",
                "display": "Line Submitted Charge Amount"
              }
            ]
          },
          "amount": {
            "value": 146.42,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt",
                "display": "Line Allowed Charge Amount"
              }
            ]
          },
          "amount": {
            "value": 146.42,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt",
                "display": "Line Beneficiary Part B Deductible Amount"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd",
                "display": "Line Processing Indicator Code"
              }
            ]
          }
        }
      ]
    }
  ],
  "total": [
    {
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/adjudication",
            "code": "submitted",
            "display": "Submitted Amount"
          }
        ],
        "text": "Submitted Amount"
      },
      "amount": {
        "value": 77.49,
        "currency": "USD"
      }
    }
  ],
  "payment": {
    "amount": {
      "value": 117.136,
      "currency": "USD"
    }
  }
}