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          "text": "Has season or migrant farm work been your or your family's main source of income at any point in past 2 years [PRAPARE]"
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      },
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        "text": "Body Weight"
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      }, {
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        "text": "Heart rate"
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          "coding": [ {
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          "text": "Has season or migrant farm work been your or your family's main source of income at any point in past 2 years [PRAPARE]"
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          "coding": [ {
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          "text": "No"
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        "code": {
          "coding": [ {
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        "code": {
          "coding": [ {
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          "text": "No"
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        "text": "Platelet [Entitic mean volume] in Blood by Automated count"
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        "coding": [ {
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          "code": "72166-2",
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        "text": "Tobacco smoking status"
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        "reference": "urn:uuid:21060120-8398-1940-3dc7-1d7f56bb2674"
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        "coding": [ {
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        "code": {
          "coding": [ {
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        "code": {
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            "display": "Has season or migrant farm work been your or your family's main source of income at any point in past 2 years [PRAPARE]"
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          "text": "Has season or migrant farm work been your or your family's main source of income at any point in past 2 years [PRAPARE]"
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        "valueCodeableConcept": {
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          "text": "No"
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        "code": {
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        "code": {
          "coding": [ {
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          "text": "Hispanic or Latino"
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        "valueCodeableConcept": {
          "coding": [ {
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          "system": "https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd",
          "code": "N",
          "display": "All other reasons for non-payment"
        }
      }, {
        "url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension",
        "valueMoney": {
          "value": 0.0,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }, {
        "url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension",
        "valueIdentifier": {
          "system": "https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num",
          "value": "002000"
        }
      } ],
      "identifier": [ {
        "system": "https://bluebutton.cms.gov/resources/variables/clm_id",
        "value": "21060120-8398-1940-95ed-c646bdb269e0"
      }, {
        "system": "https://bluebutton.cms.gov/resources/identifier/claim-group",
        "value": "99999999999"
      } ],
      "status": "active",
      "type": {
        "coding": [ {
          "system": "https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd",
          "code": "71",
          "display": "Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim"
        }, {
          "system": "https://bluebutton.cms.gov/resources/codesystem/eob-type",
          "code": "CARRIER",
          "display": "EOB Type"
        }, {
          "system": "http://hl7.org/fhir/ex-claimtype",
          "code": "professional",
          "display": "Claim Type"
        }, {
          "system": "https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd",
          "code": "O",
          "display": "Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)"
        } ]
      },
      "patient": {
        "reference": "urn:uuid:21060120-8398-1940-3dc7-1d7f56bb2674"
      },
      "billablePeriod": {
        "extension": [ {
          "url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension",
          "valueCoding": {
            "system": "https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd",
            "code": "3",
            "display": "Final Bill"
          }
        } ],
        "start": "2026-03-31T01:31:46+00:00",
        "end": "2027-03-31T01:31:46+00:00"
      },
      "provider": {
        "identifier": {
          "value": "aad125bd-437a-36ce-8c15-7dcd97531abd"
        }
      },
      "organization": {
        "identifier": {
          "value": "0d9b0d22-585e-3fd8-ab02-26b5be7915d1"
        }
      },
      "careTeam": [ {
        "sequence": 1,
        "provider": {
          "identifier": {
            "system": "http://hl7.org/fhir/sid/us-npi",
            "value": "9999991299"
          }
        },
        "role": {
          "coding": [ {
            "system": "http://hl7.org/fhir/claimcareteamrole",
            "code": "primary",
            "display": "Primary provider"
          } ]
        }
      } ],
      "insurance": {
        "coverage": {
          "reference": "#coverage"
        }
      },
      "item": [ {
        "extension": [ {
          "url": "https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension",
          "valueQuantity": {
            "value": 0
          }
        } ],
        "sequence": 1,
        "locationCodeableConcept": {
          "coding": [ {
            "system": "https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd",
            "code": "21",
            "display": "Inpatient Hospital"
          } ]
        },
        "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": 28.516000000000005,
            "system": "urn:iso:std:iso:4217",
            "code": "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": 114.06400000000002,
            "system": "urn:iso:std:iso:4217",
            "code": "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": 142.58,
            "system": "urn:iso:std:iso:4217",
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          }
        }, {
          "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": 142.58,
            "system": "urn:iso:std:iso:4217",
            "code": "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,
            "system": "urn:iso:std:iso:4217",
            "code": "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"
            } ]
          }
        } ]
      } ],
      "totalCost": {
        "value": 142.58,
        "system": "urn:iso:std:iso:4217",
        "code": "USD"
      },
      "payment": {
        "amount": {
          "value": 114.06400000000002,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    },
    "request": {
      "method": "POST",
      "url": "ExplanationOfBenefit"
    }
  } ]
}
