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<?xml version="1.0" encoding="UTF-8" ?>
<blue_button_claims>
<patient>
<name>Ellen Harrison Lu</name>
<first_name>Ellen</first_name>
<middle_name>Harrison</middle_name>
<last_name>Lu</last_name>
</patient>
<payer>
<name>Name of Insurance</name>
<payer_id>123456</payer_id>
<payer_id_type>National Payer ID</payer_id_type>
<plan_name>Name of Policy</plan_name>
<plan_id>123456</plan_id>
<member_id>W1234123456</member_id>
<member_name>Name of Plan Member</member_name>
<url>http://yourinsurer.org</url>
</payer>
<claims>
<claim>0210336239290</claim>
<type>Part B</type>
<provider>
<name>Inova Health Services</name>
<provider_id>123456789</provider_id>
<provider_id_type>National Provider ID</provider_id_type>
<provider_billing_address>601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034</provider_billing_address>
</provider>
<date>
<start_date>20101102</start_date>
<end_date>20101102</end_date>
</date>
<charges>
<price_billed>1022.5</price_billed>
<negotiated_price>782.33</negotiated_price>
<insurance_paid>625.86</insurance_paid>
<patient_responsibility>156.47</patient_responsibility>
</charges>
<service>
<name>Name of Service Provided</name>
<code_system_name>CPT</code_system_name>
<code_system>2.16.840.1.113883.6.96</code_system>
<code>28521</code>
</service>
<diagnoses>
<name>Name of Condition</name>
<code_system_name>CPT</code_system_name>
<code_system>2.16.840.1.113883.6.96</code_system>
<code>28521</code>
</diagnoses>
<diagnoses>
<name>Name of Condition</name>
<code_system_name>CPT</code_system_name>
<code_system>2.16.840.1.113883.6.96</code_system>
<code>5854</code>
</diagnoses>
<details>
<start_date>20101102</start_date>
<end_date>20101102</end_date>
<procedure_code>A0428</procedure_code>
<procedure_description>Description of Procedure</procedure_description>
<modifiers>
<description>Additional details</description>
</modifiers>
<quantity>1</quantity>
<price_billed>275</price_billed>
<negotiated_price>208.99</negotiated_price>
<patient_responsibility>66.01</patient_responsibility>
<place_of_service_code>41</place_of_service_code>
<place_of_service>Ambulance - Land</place_of_service>
<type_of_service_code>9</type_of_service_code>
<type_of_service>Other Medical Services</type_of_service>
<rendering_provider_number>Q335520003</rendering_provider_number>
<rendering_provider_npi>1023062544</rendering_provider_npi>
</details>
<details>
<start_date>20101102</start_date>
<end_date>20101102</end_date>
<procedure_code>A0428</procedure_code>
<procedure_description>Description of Procedure</procedure_description>
<modifiers>
<description>Additional details</description>
</modifiers>
<quantity>1</quantity>
<price_billed>275</price_billed>
<negotiated_price>208.99</negotiated_price>
<patient_responsibility>66.01</patient_responsibility>
<place_of_service_code>41</place_of_service_code>
<place_of_service>Ambulance - Land</place_of_service>
<type_of_service_code>9</type_of_service_code>
<type_of_service>Other Medical Services</type_of_service>
<rendering_provider_number>Q335520003</rendering_provider_number>
<rendering_provider_npi>1023062544</rendering_provider_npi>
</details>
<details>
<start_date>20101102</start_date>
<end_date>20101102</end_date>
<procedure_code>A0425</procedure_code>
<procedure_description>Description of Procedure</procedure_description>
<modifiers>
<description>Additional details</description>
</modifiers>
<quantity>44</quantity>
<price_billed>472.5</price_billed>
<negotiated_price>364.35</negotiated_price>
<patient_responsibility>108.15</patient_responsibility>
<place_of_service_code>41</place_of_service_code>
<place_of_service>Ambulance - Land</place_of_service>
<type_of_service_code>9</type_of_service_code>
<type_of_service>Other Medical Services</type_of_service>
<rendering_provider_number>Q335520003</rendering_provider_number>
<rendering_provider_npi>1023062544</rendering_provider_npi>
</details>
</claims>
<claims>
<claim>000000123456</claim>
<type>Part D</type>
<pharmacy>
<name>Costco Pharmacy</name>
<provider_id>1234567891</provider_id>
<provider_id_type>National Provider ID</provider_id_type>
<provider_billing_address>601 FIRST STREET, FORT WASHINGTON, PA 19034</provider_billing_address>
</pharmacy>
<date>20071002</date>
<drug>
<name>OXISTAT</name>
<code_system_name>RxNorm</code_system_name>
<code>00462035860</code>
<fill_number>0</fill_number>
<days_supply>30</days_supply>
</drug>
<prescriber>
<identifier>1111111111</identifier>
<name>Harvey, A. McGehee</name>
</prescriber>
</claims>
</blue_button_claims>