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{
"patient":{
"name":"Ellen Lu",
"patient_identifier":"W1234123456"
},
"insurance":{
"name":"Name of Insurance",
"payer_id":123456,
"payer_id_type":"National Payer ID",
"policy_name":"Name of Policy",
"policy_information":123456,
"member_id":"W1234123456",
"member_name":"Name of Plan Member",
"plan_name":"Name of Plan"
},
"claims":[
{
"claim":"0210336239290",
"type":"Part B",
"provider":{
"name":"Inova Health Services",
"provider_id":123456789,
"provider_id_type":"National Provider ID",
"provider_billing_address":"601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034"
},
"date":{
"start_date":20101102,
"end_date":20101102
},
"charges":{
"price_billed":1022.50,
"negotiated_price":782.33,
"insurance_paid":625.86,
"patient_responsibility":156.47
},
"service":{
"name":"Name of Service Provided",
"code_system_name":"CPT",
"code_system":"2.16.840.1.113883.6.96",
"code":28521
},
"diagnoses":[
{
"name":"Name of Condition",
"code_system_name":"CPT",
"code_system":"2.16.840.1.113883.6.96",
"code":28521
},
{
"name":"Name of Condition",
"code_system_name":"CPT",
"code_system":"2.16.840.1.113883.6.96",
"code":5854
}
],
"lines":[
{
"start_date":20101102,
"end_date":20101102,
"procedure_code":"A0428",
"procedure_description":"Description of Procedure",
"modifiers":[
{
"description":"Additional details"
}
],
"quantity":1,
"price_billed":275.00,
"negotiated_price":208.99,
"patient_responsibility":66.01,
"place_of_service_code":41,
"place_of_service:":"Ambulance - Land",
"type_of_service_code":9,
"type_of_service":"Other Medical Services",
"rendering_provider_number":"Q335520003",
"rendering_provider_npi":1023062544
},
{
"start_date":20101102,
"end_date":20101102,
"procedure_code":"A0428",
"procedure_description":"Description of Procedure",
"modifiers":[
{
"description":"Additional details"
}
],
"quantity":1,
"price_billed":275.00,
"negotiated_price":208.99,
"patient_responsibility":66.01,
"place_of_service_code":41,
"place_of_service:":"Ambulance - Land",
"type_of_service_code":9,
"type_of_service":"Other Medical Services",
"rendering_provider_number":"Q335520003",
"rendering_provider_npi":1023062544
},
{
"start_date":20101102,
"end_date":20101102,
"procedure_code":"A0425",
"procedure_description":"Description of Procedure",
"modifiers":[
{
"description":"Additional details"
}
],
"quantity":44,
"price_billed":472.50,
"negotiated_price":364.35,
"patient_responsibility":108.15,
"place_of_service_code":41,
"place_of_service:":"Ambulance - Land",
"type_of_service_code":9,
"type_of_service":"Other Medical Services",
"rendering_provider_number":"Q335520003",
"rendering_provider_npi":1023062544
}
]
},
{
"claim":"000000123456",
"type":"Part D",
"pharmacy":{
"name":"Costco Pharmacy",
"provider_id":1234567891,
"provider_id_type":"National Provider ID",
"provider_billing_address":"601 FIRST STREET, FORT WASHINGTON, PA 19034"
},
"date":20071002,
"drug":{
"name":"OXISTAT",
"code_system_name":"RxNorm",
"code":"00462035860",
"fill_number":0,
"days_supply":30
},
"prescriber":{
"identifier":1111111111,
"name":"Harvey, A. McGehee"
}
}
]
}