{
  "information": [
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd",
            "display": "Dispense as Written (DAW) Product Selection Code"
          }
        ]
      },
      "sequence": 1,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/daw_prod_slctn_cd",
            "code": "0",
            "display": "No Product Selection Indicated (may also have missing values)"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd",
            "display": "Dispensing Status Code"
          }
        ]
      },
      "sequence": 2,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/dspnsng_stus_cd",
            "code": "C",
            "display": "Completion of partial fill"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd",
            "display": "Drug Coverage Status Code"
          }
        ]
      },
      "sequence": 3,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd",
            "code": "C",
            "display": "Covered"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/rx_orgn_cd",
            "display": "Prescription Origination Code"
          }
        ]
      },
      "sequence": 4,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/rx_orgn_cd",
            "code": "3",
            "display": "Electronic"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd",
            "display": "Brand-Generic Code Reported by Submitting Plan"
          }
        ]
      },
      "sequence": 5,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/brnd_gnrc_cd",
            "code": "G",
            "display": "Generic Null/missing"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd",
            "display": "Pharmacy service type code"
          }
        ]
      },
      "sequence": 6,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/phrmcy_srvc_type_cd"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd",
            "display": "Patient Residence Code"
          }
        ]
      },
      "sequence": 7,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/ptnt_rsdnc_cd",
            "code": "90"
          }
        ]
      }
    },
    {
      "category": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/codesystem/information",
            "code": "https://bluebutton.cms.gov/resources/variables/submsn_clr_cd",
            "display": "Submission clarification code"
          }
        ]
      },
      "sequence": 8,
      "code": {
        "coding": [
          {
            "system": "https://bluebutton.cms.gov/resources/variables/submsn_clr_cd",
            "code": "21",
            "display": "LTC dispensing rule for <=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing"
          }
        ]
      }
    }
  ],
  "facility": {
    "identifier": {
      "value": "999999999999999",
      "system": "http://hl7.org/fhir/sid/us-npi"
    }
  },
  "identifier": [
    {
      "value": "-3410339348",
      "system": "https://bluebutton.cms.gov/resources/variables/pde_id"
    },
    {
      "value": "4669765623",
      "system": "https://bluebutton.cms.gov/resources/identifier/claim-group"
    },
    {
      "value": "33437629246",
      "system": "https://bluebutton.cms.gov/resources/variables/rx_srvc_rfrnc_num"
    }
  ],
  "meta": {
    "lastUpdated": "2020-01-10T08:42:58.808Z",
    "versionId": "9000000000000"
  },
  "status": "active",
  "item": [
    {
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/codesystem/adjudication",
                "code": "https://bluebutton.cms.gov/resources/variables/cvrd_d_plan_pd_amt",
                "display": "Amount paid by Part D plan for the PDE (drug is covered by Part D)"
              }
            ]
          },
          "reason": {
            "coding": [
              {
                "system": "https://bluebutton.cms.gov/resources/variables/drug_cvrg_stus_cd",
                "code": "C",
                "display": "Covered"
              }
            ]
          },
          "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/gdc_blw_oopt_amt",
                "display": "Gross Drug Cost Below Part D Out-of-Pocket Threshold (GDCB)"
              }
            ]
          },
          "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/gdc_abv_oopt_amt",
                "display": "Gross Drug Cost Above Part D Out-of-Pocket Threshold (GDCA)"
              }
            ]
          },
          "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/ptnt_pay_amt",
                "display": "Amount Paid by Patient"
              }
            ]
          },
          "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/othr_troop_amt",
                "display": "Other True Out-of-Pocket (TrOOP) 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/lics_amt",
                "display": "Amount paid for the PDE by Part D low income subsidy"
              }
            ]
          },
          "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/plro_amt",
                "display": "Reduction in patient liability due to payments by other payers (PLRO)"
              }
            ]
          },
          "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/tot_rx_cst_amt",
                "display": "Total drug cost (Part D)"
              }
            ]
          },
          "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/rptd_gap_dscnt_num",
                "display": "Gap Discount Amount"
              }
            ]
          },
          "amount": {
            "value": 0,
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        }
      ],
      "sequence": 1,
      "servicedDate": "2016-06-01",
      "quantity": {
        "value": 30
      },
      "careTeamLinkId": [
        2
      ],
      "service": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/ndc",
            "code": "60505257908",
            "display": "ATORVASTATIN CALCIUM - ATORVASTATIN CALCIUM TRIHYDRATE"
          }
        ]
      }
    }
  ],
  "patient": {
    "reference": "Patient/dc793caf0d58"
  },
  "organization": {
    "identifier": {
      "value": "999999999999999",
      "system": "http://hl7.org/fhir/sid/us-npi"
    }
  },
  "resourceType": "ExplanationOfBenefit",
  "careTeam": [
    {
      "sequence": 2,
      "provider": {
        "identifier": {
          "value": "999999999999999",
          "system": "http://hl7.org/fhir/sid/us-npi"
        }
      },
      "role": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/claimcareteamrole",
            "code": "primary",
            "display": "Primary provider"
          }
        ]
      }
    }
  ],
  "id": "dc793caf0d5817e9f930617b54fee112916ad85cb64d3aeb",
  "insurance": {
    "coverage": {
      "reference": "Coverage/dc793caf0d58ad1fb66cbe7ba7e20b8191fe69f72524dcbc"
    }
  },
  "type": {
    "coding": [
      {
        "system": "https://bluebutton.cms.gov/resources/codesystem/eob-type",
        "code": "PDE"
      },
      {
        "system": "http://hl7.org/fhir/ex-claimtype",
        "code": "pharmacy",
        "display": "Pharmacy"
      }
    ]
  }
}