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McGehee" + } + } + ] +} \ No newline at end of file diff --git a/Medicare/medicare_bbp.txt b/Medicare/medicare_bbp.txt new file mode 100644 index 0000000..4426c8b --- /dev/null +++ b/Medicare/medicare_bbp.txt @@ -0,0 +1,2117 @@ +-------------------------------- +MYMEDICARE.GOV PERSONAL HEALTH INFORMATION + +-------------------------------- +**********CONFIDENTIAL*********** + +Produced by the Blue Button (v2.0) + +02/04/2015 9:18 AM + + + + +-------------------------------- +Demographic + +-------------------------------- + +Source: MyMedicare.gov + + + +Name: JOHN DOE + +Date of Birth: 1/1/1910 + +Address Line 1: 123 ANY ROAD + +Address Line 2: + +City: ANYTOWN + +State: IN + +Zip: 46250 + +Phone Number: 215-248-0684 + +Email: + +Part A Effective Date: 2/1/2014 + +Part B Effective Date: 2/1/2014 + + + +-------------------------------- +Emergency Contact + +-------------------------------- + +Source: Self-Entered + + + +Contact Name: Billy Bigelow2 + +Address Type:Home + +Address Line 1: 1234 Carnival Lane + +Address Line 2: Lobster Bay, ME 11112 + +City: + +State: + +Zip: 11111 + +Relationship: Friend + +Home Phone: + +Work Phone: + +Mobile Phone: + +Email Address: + + + +Contact Name: Enoch Snow + +Address Type:Home + +Address Line 1: 2345 Fish Head Cove + +Address Line 2: Lobster Bay, ME 11112 + +City: + +State: + +Zip: + +Relationship: Friend + +Home Phone: + +Work Phone: + +Mobile Phone: + +Email Address: + + + +-------------------------------- +Self Reported Medical Conditions + +-------------------------------- + +Source: Self-Entered + + + +Condition Name: Allergies + +Medical Condition Start Date: 1/29/2013 + +Medical Condition End Date: + + + +Condition Name: Arthritis + +Medical Condition Start Date: 8/1/1960 + +Medical Condition End Date: 12/31/1980 + + + +Condition Name: Broken Wrist + +Medical Condition Start Date: 2/6/1910 + +Medical Condition End Date: 2/6/2013 + + + +Condition Name: Other + +Medical Condition Start Date: 2/1/2011 + +Medical Condition End Date: + + + +Condition Name: Other + +Medical Condition Start Date: 2/28/2012 + +Medical Condition End Date: + + + +-------------------------------- +Self Reported Allergies + +-------------------------------- + +Source: Self-Entered + + + +Allergy Name: Antibotic + +Type: Drugs + +Reaction: + +Severity: + +Diagnosed: + +Treatment: + +First Episode Date: + +Last Episode Date: + +Last Treatment Date: + +Comments: + + + +Allergy Name: Corn + +Type: Food + +Reaction: Blisters + +Severity: Mild + +Diagnosed: Yes + +Treatment: Other + +First Episode Date: + +Last Episode Date: + +Last Treatment Date: + +Comments: + + + +Allergy Name: Milk + +Type: Food + +Reaction: Anaphylaxis + +Severity: Severe + +Diagnosed: Yes + +Treatment: Epinephrine (Epi-Pen) + +First Episode Date: 3/21/1985 + +Last Episode Date: 3/31/2012 + +Last Treatment Date: 3/31/2012 + +Comments: + + + +Allergy Name: Other - other + +Type: Other - other + +Reaction: + +Severity: + +Diagnosed: + +Treatment: + +First Episode Date: + +Last Episode Date: + +Last Treatment Date: + +Comments: + + + +-------------------------------- +Self Reported Implantable Device + +-------------------------------- + +Source: Self-Entered + + + +Device Name: COronary stent + +Date Implanted: 11/27/2005 + + + +Device Name: Knee replacement + +Date Implanted: 2/2/2014 + + + +Device Name: Pace maker + +Date Implanted: 2/28/2012 + + + +Device Name: foot + +Date Implanted: 9/9/1984 + + + +Device Name: hearing aid + +Date Implanted: 1/1/2013 + + + +Device Name: nov20 + +Date Implanted: 12/15/2007 + + + +-------------------------------- +Self Reported Immunizations + +-------------------------------- + +Source: Self-Entered + + + +Immunization Name: shingles + +Date Administered:2/3/2010 + +Method: Injection + +Were you vaccinated in the US: Yes + +Comments: + +Booster 1 Date: 2/4/2011 + +Booster 2 Date: 4/6/2012 + +Booster 3 Date: + + + +-------------------------------- +Self Reported Labs and Tests + +-------------------------------- + +Source: Self-Entered + + + +Test/Lab Type: Test + +Date Taken: 1/2/2013 + +Administered by: Inova + +Requesting Doctor: Dr. John Doe + +Reason Test/Lab Requested: + +Results: + +Comments: + + + +-------------------------------- +Self Reported Vital Statistics + +-------------------------------- + +Source: Self-Entered + + + +Vital Statistic Type: Glucose + +Date: 2/7/2008 + +Time: 12:00 AM + +Reading/Value: 322 + +Comments: + + + +Vital Statistic Type: Glucose + +Date: 4/3/2009 + +Time: 12:02 PM + +Reading/Value: 24 + +Comments: fwrqwrgreg + + + +Vital Statistic Type: Glucose + +Date: 5/14/2009 + +Time: 12:17 PM + +Reading/Value: 134 + +Comments: rwrtrt + + + +Vital Statistic Type: Otro - other + +Date: 1/1/1939 + +Time: 12:00 AM + +Reading/Value: other + +Comments: + + + +Vital Statistic Type: Pulse + +Date: 4/6/2013 + +Time: 12:00 AM + +Reading/Value: 333 + +Comments: + + + +Vital Statistic Type: Pulse + +Date: 3/2/2011 + +Time: 12:09 AM + +Reading/Value: 80 + +Comments: wwqrgtrt + + + +Vital Statistic Type: Temperature + +Date: 6/5/2009 + +Time: 8:06 AM + +Reading/Value: 100 + +Comments: fwqerqwr + + + +Vital Statistic Type: Temperature + +Date: 4/4/2008 + +Time: 9:02 AM + +Reading/Value: 99 + +Comments: + + + +-------------------------------- +Family Medical History + +-------------------------------- + +Source: Self-Entered + + + +Family Member: Daughter + +Type: Maternal + +DOB:1/1/1994 + +DOD: + +Age: 31 + +Type: Allergy + +Description: Dyes + +Type: Condition + +Description: Diabetes, Type 2 + +Description: Skin Cancer + + +Family Member: Brother + +Type: + +DOB:4/4/2012 + +DOD: + +Age: + +Type: Allergy + +Description: Chemotherapy + +Type: Condition + +Description: Alzheimer's Disease + + +-------------------------------- +Drugs + +-------------------------------- + +Source: Self-Entered + + + +Drug Name: Abacavir TAB 300MG + +Supply: 60 Every 1 Month + +Orig Drug Entry: Abacavir + + + +Drug Name: Abilify Maintena INJ 300MG + +Supply: 1 X Vial Every 1 Month + +Orig Drug Entry: Abilify Maintena + + + +Drug Name: Amlodipine Besylate TAB 10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate + + + +Drug Name: Amlodipine Besylate TAB 2.5MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate + + + +Drug Name: Amlodipine Besylate TAB 5MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-20MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-40MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-80MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 5-10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Caduet + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 5-80MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Androgel Pump GEL 1.62% + +Supply: 2 X 75GM Pump Bottle (sold in a package of 1 pump bottle) Every 1 Month + +Orig Drug Entry: Androgel Pump + + + +Drug Name: Drospirenone/Ethinyl Estradiol TAB 3-0.03MG + +Supply: 28 Every 1 Month + +Orig Drug Entry: Yasmin 28 + + + +Drug Name: Gabapentin CAP 100MG + +Supply: 90 Every 1 Month + +Orig Drug Entry: Gabapentin + + + +Drug Name: Gabapentin SOL 250/5ML + +Supply: 1 X 470ML Bottle Every 1 Month + +Orig Drug Entry: Gabapentin + + + +Drug Name: Jakafi TAB 10MG + +Supply: 60 Every 1 Month + +Orig Drug Entry: Jakafi + + + +Drug Name: Losartan Potassium/Hydrochlorothiazide TAB 100-25 + +Supply: 30 Every 1 Month + +Orig Drug Entry: Losartan Potassium/Hydrochlorothiazide + + + +Drug Name: Montelukast Sodium TAB 10MG + +Supply: 90 Every 3 Month + +Orig Drug Entry: Montelukast Sodium + + + +Drug Name: Omeprazole CAP 20MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Omeprazole + + + +Drug Name: Rabavert INJ + +Supply: 2 X Vial (sold in a package of 2) Every 12 Month + +Orig Drug Entry: Rabavert + + + +Drug Name: Tabloid TAB 40MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Tabloid + + + +Drug Name: Vagifem TAB 10MCG + +Supply: 8 Every 1 Month + +Orig Drug Entry: Vagifem + + + +Drug Name: Zafirlukast TAB 20MG + +Supply: 60 Every 1 Month + +Orig Drug Entry: Zafirlukast + + + +Drug Name: Zaleplon CAP 10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Zaleplon + + + +Drug Name: Zaltrap INJ 100/4ML + +Supply: 1 X 4ML Vial Every 1 Month + +Orig Drug Entry: Zaltrap + + + +-------------------------------- +Preventive Services + +-------------------------------- + +Source: MyMedicare.gov + + + +Description: ABDOMINAL AORTIC ANEURYSM + +Next Eligible Date: 2/1/2014 + +Last Date of Service: + + + +Description: CARDIOVASCULAR + +Next Eligible Date: 2/1/2014 + +Last Date of Service: + + + +Description: PPV + +Next Eligible Date: 2/1/2014 + +Last Date of Service: + + + +Description: PROSTATE + +Next Eligible Date: 2/1/2014 + +Last Date of Service: 3/26/2012 + + + +Description: PSA + +Next Eligible Date: 2/1/2014 + +Last Date of Service: 3/26/2012 + + + +Description: ANNUAL WELLNESS VISIT + +Next Eligible Date: 2/1/2015 + +Last Date of Service: + + + +Description: ALCOHOL MISUSE SCREENING + +Next Eligible Date: + +Last Date of Service: + + + +Description: CARDIOVASCULAR DISEASE (BEHAVIORAL THERAPY) + +Next Eligible Date: + +Last Date of Service: + + + +Description: COLORECTAL + +Next Eligible Date: + +Last Date of Service: 4/21/2011 + + + +Description: DEPRESSION SCREENING + +Next Eligible Date: + +Last Date of Service: + + + +Description: DIABETES + +Next Eligible Date: + +Last Date of Service: 5/21/2012 + + + +Description: HIGH INTENSITY BEHAVIORAL COUNSELING + +Next Eligible Date: + +Last Date of Service: + + + +Description: OBESITY COUNSELING + +Next Eligible Date: + +Last Date of Service: + + + +Description: PHYSICAL + +Next Eligible Date: + +Last Date of Service: + + + +Description: SMOKING CESSATION (counseling to stop smoking) + +Next Eligible Date: + +Last Date of Service: + + + +-------------------------------- +Providers + +-------------------------------- + +Source: Self-Entered + + + +Provider Name: ANGELO SCOTTI + +Provider Address: 180 WHITE RD LITTLE SILVER, NJ 07739 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: DOUGLAS KNOX + +Provider Address: 1104 E 23RD ST LAWRENCE, KS 66046 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: SIAMAK RASSADI + +Provider Address: 1331 N 7TH ST PHOENIX, AZ 85006 + +Type: Physician & Other Healthcare Professional + +Specialty: Cardiac Electrophysiology,Cardiovascular Disease (Cardiology) + +Medicare Provider: May Accept Medicare + + + +Provider Name: PETER LEAVITT + +Provider Address: 2965 NECONNERS AVE BEND, OR 97701 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: JOHN KENNEDY + +Provider Address: 8888 KEYSTONE XING INDIANAPOLIS, IN 46240 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: REBECCA KELLY + +Provider Address: 7250 CLEARVISTA DR INDIANAPOLIS, IN 46256 + +Type: Physician & Other Healthcare Professional + +Specialty: Addiction Medicine + +Medicare Provider: Yes + + + +Provider Name: RILEY HOSPITAL - PEDS DIALYSIS + +Provider Address: 705 RILEY HOSPITAL DRIVE INDIANAPOLIS, IN 46202 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FMC - SHADELAND STATION + +Provider Address: 7155 SHADELAND STATION STE 130 INDIANAPOLIS, IN 46256 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: IU HEALTH - HOME DIALYSIS + +Provider Address: 8803 N. MERIDIAN ST., STE 150 INDIANAPOLIS, IN 46260 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: MESA VISTA OF BOULDER + +Provider Address: 2121 MESA DRIVE BOULDER, CO 80304 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: FAIRBANKS + +Provider Address: 8102 CLEARVISTA PARKWAY INDIANAPOLIS, IN 46256 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: ALLIANCE HOME HEALTH SERVICES INC + +Provider Address: 9615 N COLLEGE AVE INDIANAPOLIS, IN 46280 + +Type: Home Health + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: THE VIRGINIAN + +Provider Address: 9229 ARLINGTON BLVD FAIRFAX, VA 22031 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: KINDRED TRANSITIONAL CARE & REHAB-ALLISON POINTE + +Provider Address: 5226 E 82ND ST INDIANAPOLIS, IN 46250 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: INDIANA HEART HOSPITAL THE + +Provider Address: 8075 N SHADELAND AVE INDIANAPOLIS, IN 46250 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: COMMUNITY HOSPITAL NORTH + +Provider Address: 7150 CLEARVISTA DR INDIANAPOLIS, IN 46256 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FORUM AT THE CROSSING + +Provider Address: 8505 WOODFIELD CROSSING BLVD INDIANAPOLIS, IN 46240 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: BEAUMONT HOSPITAL, TROY + +Provider Address: 44201 DEQUINDRE ROAD TROY, MI 48085 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: DAVITA - EAGLE HIGHLANDS + +Provider Address: 6925 SHORE TERRACE INDIANAPOLIS, IN 46254 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FMC - CARMEL + +Provider Address: 12400 NORTH MERIDIAN ST., STE 200 CARMEL, IN 46032 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: DSI - NW INDIANAPOLIS RENAL CENTER + +Provider Address: 6488 CORPORATE DRIVE INDIANAPOLIS, IN 46268 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: GEORGE WASHINGTON UNIV HOSPITAL + +Provider Address: 900 23RD ST NW WASHINGTON, DC 20037 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: DAVITA - CARMEL HEALTH AND LIVING + +Provider Address: 118 MEDICAL DRIVE, SUITE 114 CARMEL, IN 46032 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FMC-INDIANAPOLIS MIDTOWN + +Provider Address: 3007 DR ANDREW J BROWN AVENUE INDIANAPOLIS, IN 46205 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: MILLER'S SENIOR LIVING COMMUNITY + +Provider Address: 8400 CLEARVISTA PL INDIANAPOLIS, IN 46256 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: TEST QT + +Provider Address: COEBURN, VA 24230 + +Type: Home Health + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: ADVANCED HOME CARE, INC + +Provider Address: 165 PLAZA ROAD, SUITE 20 WISE, VA 24293 + +Type: Home Health + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: TEST NHC QT + +Provider Address: 0 24230 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: HERITAGE HALL WISE + +Provider Address: 9434 COEBURN MOUNTAIN ROAD WISE, VA 24293 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: QT JAN 15 TEST + +Provider Address: 121 HOME STREET COEBURN, VA 24230 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: NORTON COMMUNITY HOSPITAL + +Provider Address: 100 15TH ST NW NORTON, VA 24273 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +-------------------------------- +Pharmacies + +-------------------------------- + +Source: Self-Entered + + + +Pharmacy Name: Castleton Integrative Health 8208 Allisonville Rd Indianapolis, IN 46250 + +Pharmacy Phone: 317-849-1222 + + + +Pharmacy Name: Costco Pharmacy Indianapolis, IN 462506110 East 86th Street Castleton, IN 46250 + +Pharmacy Phone: 317-558-1452 + + + +-------------------------------- +Plans + +-------------------------------- + +Source: MyMedicare.gov + + + +Contract ID/Plan ID: S1111/801 + +Plan Period: 12/01/2012 - current + +Plan Name: + +Marketing Name: + +Plan Address: + +Plan Type: 11 - Medicare Prescription Drug Plan + + + +-------------------------------- +Employer Subsidy + +-------------------------------- + +Source: MyMedicare.gov + + + + +-------------------------------- +Primary Insurance + +-------------------------------- + +Source: MyMedicare.gov + + + + +-------------------------------- +Other Insurance + +-------------------------------- + +Source: MyMedicare.gov + + + +MSP Type: + +Policy Number: 30002 + +Insurer Name: UNITEDHEALTH GROUP + +Insurer Address: 601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034 + +Effective Date: 10/01/1984 + +Termination Date: + + + +-------------------------------- +Claim Summary + +-------------------------------- + +Source: MyMedicare.gov + + + +Claim Number: 11122233330000 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $135.00 + +Medicare Approved: $92.53 + +Provider Paid: $74.02 + +You May be Billed: $18.51 + +Claim Type: DME + +Diagnosis Code 1: 32723 +Diagnosis Code 2: 78051 + +-------------------------------- +Claim Lines for Claim Number: 11122233330000 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: E0601 - Continuous Positive Airway Pressure (Cpap) Device + +Modifier 1/Description: MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + +Modifier 2/Description: KX - Requirements Specified In The Medical Policy Have Been Met + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $135.00 + +Allowed Amount: $92.53 + +Non-Covered: $42.47 + +Place of Service/Description: 12 - Home + +Type of Service/Description: R - Rental of DME + +Rendering Provider No: DMEPROVIDR + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 11122233320000 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $135.00 + +Medicare Approved: $90.45 + +Provider Paid: $72.36 + +You May be Billed: $18.09 + +Claim Type: DME + +Diagnosis Code 1: 32723 +Diagnosis Code 2: 78051 + +-------------------------------- +Claim Lines for Claim Number: 11122233320000 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: E0601 - Continuous Positive Airway Pressure (Cpap) Device + +Modifier 1/Description: MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + +Modifier 2/Description: KX - Requirements Specified In The Medical Policy Have Been Met + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $135.00 + +Allowed Amount: $90.45 + +Non-Covered: $44.55 + +Place of Service/Description: 12 - Home + +Type of Service/Description: R - Rental of DME + +Rendering Provider No: DMEPROVIDR + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555100 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: * Not Available * + +Medicare Approved: * Not Available * + +Provider Paid: * Not Available * + +You May be Billed: * Not Available * + +Claim Type: PartB + +Diagnosis Code 1: 7392 +Diagnosis Code 2: 7241 +Diagnosis Code 3: 7393 +Diagnosis Code 4: 7391 + +-------------------------------- +Claim Lines for Claim Number: 2333444555100 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 98941 - Chiropractic Manipulative Treatment, 3 To 4 Spinal Regions + +Modifier 1/Description: GA - Waiver Of Liability Statement Issued As Required By Payer Policy, Individual Case + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 2 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: G0283 - Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound + +Modifier 1/Description: GY - Item Or Service Statutorily Excluded, Does Not Meet The Definition Of Any Medicare Benefit Or, + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555500 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $1,022.50 + +Medicare Approved: $782.33 + +Provider Paid: $625.86 + +You May be Billed: $156.47 + +Claim Type: PartB + +Diagnosis Code 1: 70700 + +-------------------------------- +Claim Lines for Claim Number: 2333444555500 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls) + +Modifier 1/Description: RH + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $275.00 + +Allowed Amount: $208.99 + +Non-Covered: $66.01 + +Place of Service/Description: 41 - 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patient + + + Androgel Pump GEL 1.62% + 2 X 75GM Pump Bottle (sold in a package of 1 pump bottle) Every 1 Month + Androgel Pump + Drugs + patient + + + Drospirenone/Ethinyl Estradiol TAB 3-0.03MG + 28 Every 1 Month + Yasmin 28 + Drugs + patient + + + Gabapentin CAP 100MG + 90 Every 1 Month + Gabapentin + Drugs + patient + + + Gabapentin SOL 250/5ML + 1 X 470ML Bottle Every 1 Month + Gabapentin + Drugs + patient + + + Jakafi TAB 10MG + 60 Every 1 Month + Jakafi + Drugs + patient + + + Losartan Potassium/Hydrochlorothiazide TAB 100-25 + 30 Every 1 Month + Losartan Potassium/Hydrochlorothiazide + Drugs + patient + + + Montelukast Sodium TAB 10MG + 90 Every 3 Month + Montelukast Sodium + Drugs + patient + + + Omeprazole CAP 20MG + 30 Every 1 Month + Omeprazole + Drugs + patient + + + Rabavert INJ + 2 X Vial (sold in a package of 2) Every 12 Month + Rabavert + Drugs + patient + + + Tabloid TAB 40MG + 30 Every 1 Month + Tabloid + Drugs + patient + + + Vagifem TAB 10MCG + 8 Every 1 Month + Vagifem + Drugs + patient + + + Zafirlukast TAB 20MG + 60 Every 1 Month + Zafirlukast + Drugs + patient + + + Zaleplon CAP 10MG + 30 Every 1 Month + Zaleplon + Drugs + patient + + + Zaltrap INJ 100/4ML + 1 X 4ML Vial Every 1 Month + Zaltrap + Drugs + patient + + + Preventive Services + ABDOMINAL AORTIC ANEURYSM + 20140201 + + Preventive Services + MyMedicare.gov + + + CARDIOVASCULAR + 20140201 + + Preventive Services + MyMedicare.gov + + + PPV + 20140201 + + Preventive Services + MyMedicare.gov + + + PROSTATE + 20140201 + 20120326 + Preventive Services + MyMedicare.gov + + + PSA + 20140201 + 20120326 + Preventive Services + MyMedicare.gov + + + ANNUAL WELLNESS VISIT + 20150201 + + Preventive Services + MyMedicare.gov + + + ALCOHOL MISUSE SCREENING + + + Preventive Services + MyMedicare.gov + + + CARDIOVASCULAR DISEASE (BEHAVIORAL THERAPY) + + + Preventive Services + MyMedicare.gov + + + COLORECTAL + + 20110421 + Preventive Services + MyMedicare.gov + + + DEPRESSION SCREENING + + + Preventive Services + MyMedicare.gov + + + DIABETES + + 20120521 + Preventive Services + MyMedicare.gov + + + HIGH INTENSITY BEHAVIORAL COUNSELING + + + Preventive Services + MyMedicare.gov + + + OBESITY COUNSELING + + + Preventive Services + MyMedicare.gov + + + PHYSICAL + + + Preventive Services + MyMedicare.gov + + + SMOKING CESSATION (counseling to stop smoking) + + + Preventive Services + MyMedicare.gov + + + Providers + ANGELO SCOTTI + 180 WHITE RD LITTLE SILVER, NJ 07739 + Physician & Other Healthcare Professional + + Yes + Providers + patient + + + DOUGLAS KNOX + 1104 E 23RD ST LAWRENCE, KS 66046 + Physician & Other Healthcare Professional + + Yes + Providers + patient + + + SIAMAK RASSADI + 1331 N 7TH ST PHOENIX, AZ 85006 + Physician & Other Healthcare Professional + Cardiac Electrophysiology,Cardiovascular Disease (Cardiology) + May Accept Medicare + Providers + patient + + + PETER LEAVITT + 2965 NECONNERS AVE BEND, OR 97701 + Physician & Other Healthcare Professional + + Yes + Providers + patient + + + JOHN KENNEDY + 8888 KEYSTONE XING INDIANAPOLIS, IN 46240 + Physician & Other Healthcare Professional + + Yes + Providers + patient + + + REBECCA KELLY + 7250 CLEARVISTA DR INDIANAPOLIS, IN 46256 + Physician & Other Healthcare Professional + Addiction Medicine + Yes + Providers + patient + + + RILEY HOSPITAL - PEDS DIALYSIS + 705 RILEY HOSPITAL DRIVE INDIANAPOLIS, IN 46202 + Dialysis Facility + + Not Available + Providers + patient + + + FMC - SHADELAND STATION + 7155 SHADELAND STATION STE 130 INDIANAPOLIS, IN 46256 + Dialysis Facility + + Not Available + Providers + patient + + + IU HEALTH - HOME DIALYSIS + 8803 N. MERIDIAN ST., STE 150 INDIANAPOLIS, IN 46260 + Dialysis Facility + + Not Available + Providers + patient + + + MESA VISTA OF BOULDER + 2121 MESA DRIVE BOULDER, CO 80304 + Nursing Home + + Yes + Providers + patient + + + FAIRBANKS + 8102 CLEARVISTA PARKWAY INDIANAPOLIS, IN 46256 + Hospital + + Not Available + Providers + patient + + + ALLIANCE HOME HEALTH SERVICES INC + 9615 N COLLEGE AVE INDIANAPOLIS, IN 46280 + Home Health + + Not Available + Providers + patient + + + THE VIRGINIAN + 9229 ARLINGTON BLVD FAIRFAX, VA 22031 + Nursing Home + + Yes + Providers + patient + + + KINDRED TRANSITIONAL CARE & REHAB-ALLISON POINTE + 5226 E 82ND ST INDIANAPOLIS, IN 46250 + Nursing Home + + Yes + Providers + patient + + + INDIANA HEART HOSPITAL THE + 8075 N SHADELAND AVE INDIANAPOLIS, IN 46250 + Hospital + + Not Available + Providers + patient + + + COMMUNITY HOSPITAL NORTH + 7150 CLEARVISTA DR INDIANAPOLIS, IN 46256 + Hospital + + Not Available + Providers + patient + + + FORUM AT THE CROSSING + 8505 WOODFIELD CROSSING BLVD INDIANAPOLIS, IN 46240 + Nursing Home + + Not Available + Providers + patient + + + BEAUMONT HOSPITAL, TROY + 44201 DEQUINDRE ROAD TROY, MI 48085 + Hospital + + Not Available + Providers + patient + + + DAVITA - EAGLE HIGHLANDS + 6925 SHORE TERRACE INDIANAPOLIS, IN 46254 + Dialysis Facility + + Not Available + Providers + patient + + + FMC - CARMEL + 12400 NORTH MERIDIAN ST., STE 200 CARMEL, IN 46032 + Dialysis Facility + + Not Available + Providers + patient + + + DSI - NW INDIANAPOLIS RENAL CENTER + 6488 CORPORATE DRIVE INDIANAPOLIS, IN 46268 + Dialysis Facility + + Not Available + Providers + patient + + + GEORGE WASHINGTON UNIV HOSPITAL + 900 23RD ST NW WASHINGTON, DC 20037 + Hospital + + Not Available + Providers + patient + + + DAVITA - CARMEL HEALTH AND LIVING + 118 MEDICAL DRIVE, SUITE 114 CARMEL, IN 46032 + Dialysis Facility + + Not Available + Providers + patient + + + FMC-INDIANAPOLIS MIDTOWN + 3007 DR ANDREW J BROWN AVENUE INDIANAPOLIS, IN 46205 + Dialysis Facility + + Not Available + Providers + patient + + + MILLER'S SENIOR LIVING COMMUNITY + 8400 CLEARVISTA PL INDIANAPOLIS, IN 46256 + Nursing Home + + Yes + Providers + patient + + + TEST QT + COEBURN, VA 24230 + Home Health + + Not Available + Providers + patient + + + ADVANCED HOME CARE, INC + 165 PLAZA ROAD, SUITE 20 WISE, VA 24293 + Home Health + + Not Available + Providers + patient + + + TEST NHC QT + 0 24230 + Nursing Home + + Not Available + Providers + patient + + + HERITAGE HALL WISE + 9434 COEBURN MOUNTAIN ROAD WISE, VA 24293 + Nursing Home + + Yes + Providers + patient + + + QT JAN 15 TEST + 121 HOME STREET COEBURN, VA 24230 + Hospital + + Not Available + Providers + patient + + + NORTON COMMUNITY HOSPITAL + 100 15TH ST NW NORTON, VA 24273 + Hospital + + Not Available + Providers + patient + + + Pharmacies + Castleton Integrative Health 8208 Allisonville Rd Indianapolis, IN 46250 + 317-849-1222 + Pharmacies + patient + + + Costco Pharmacy Indianapolis, IN 462506110 East 86th Street Castleton, IN 46250 + 317-558-1452 + Pharmacies + patient + + + Plans + S1111/801 + 12/01/2012 - current + + + + 11 - Medicare Prescription Drug Plan + Plans + MyMedicare.gov + + + + 30002 + UNITEDHEALTH GROUP + 601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034 + 19841001 + + Other Insurance + MyMedicare.gov + + + Claim Summary + 11122233330000 + No Information Available + + + 20140105 + 20140105 + + + $135.00 + $92.53 + $74.02 + $18.51 + + DME + 32723 + 78051 + Claim Summary + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + E0601 - Continuous Positive Airway Pressure (Cpap) Device + MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + KX - Requirements Specified In The Medical Policy Have Been Met + + + 1 + $135.00 + $92.53 + $42.47 + 12 - Home + R - Rental of DME + DMEPROVIDR + + Claim Lines for Claim Number + MyMedicare.gov + 11122233330000 +
+ + + claim Header + 11122233320000 + No Information Available + + + 20140105 + 20140105 + + + $135.00 + $90.45 + $72.36 + $18.09 + + DME + 32723 + 78051 + claim Header + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + E0601 - Continuous Positive Airway Pressure (Cpap) Device + MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + KX - Requirements Specified In The Medical Policy Have Been Met + + + 1 + $135.00 + $90.45 + $44.55 + 12 - Home + R - Rental of DME + DMEPROVIDR + + Claim Lines for Claim Number + MyMedicare.gov + 11122233320000 +
+ + + claim Header + 2333444555100 + No Information Available + + + 20140105 + 20140105 + + + * Not Available * + * Not Available * + * Not Available * + * Not Available * + + PartB + 7392 + 7241 + 7393 + 7391 + claim Header + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + 98941 - Chiropractic Manipulative Treatment, 3 To 4 Spinal Regions + GA - Waiver Of Liability Statement Issued As Required By Payer Policy, Individual Case + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555100 +
+
+ 2 + 20140105 + 20140105 + G0283 - Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound + GY - Item Or Service Statutorily Excluded, Does Not Meet The Definition Of Any Medicare Benefit Or, + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555100 +
+ + + claim Header + 2333444555500 + No Information Available + + + 20140105 + 20140105 + + + $1,022.50 + $782.33 + $625.86 + $156.47 + + PartB + 70700 + claim Header + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls) + RH + + + + 1 + $275.00 + $208.99 + $66.01 + 41 - Ambulance - Land + 9 - Other Medical Services + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555500 +
+
+ 2 + 20140105 + 20140105 + A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls) + HR - Family/Couple With Client Present + + + + 1 + $275.00 + $208.99 + $66.01 + 41 - Ambulance - Land + 9 - Other Medical Services + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555500 +
+
+ 3 + 20140105 + 20140105 + A0425 - Ground Mileage, Per Statute Mile + RH + + + + 44 + $472.50 + $364.35 + $108.15 + 41 - Ambulance - Land + 9 - Other Medical Services + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555500 +
+ + + claim Header + 2333444555200 + No Information Available + + + 20140105 + 20140105 + + + * Not Available * + * Not Available * + * Not Available * + * Not Available * + + PartB + 2163 + claim Header + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + 99213 - Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes + + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 22 - Outpatient Hospital + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555200 +
+ + + claim Header + 2333444555300 + No Information Available + + + 20140105 + 20140105 + + + * Not Available * + * Not Available * + * Not Available * + * Not Available * + + PartB + 28521 + 5854 + claim Header + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + J2916 - Injection, Sodium Ferric Gluconate Complex In Sucrose Injection, 12.5 Mg + + + + + 10 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555300 +
+
+ 2 + 20140105 + 20140105 + 36000 - Insertion Of Needle Or Catheter Into A Vein + + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 2 - Surgery + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555300 +
+
+ 3 + 20140105 + 20140105 + 90765 - Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); In + + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555300 +
+
+ 4 + 20140105 + 20140105 + 90775 - Therapeutic, Prophylactic Or Diagnostic Injection (Specify Substance Or Drug); Each Addition + + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555300 +
+
+ 5 + 20140105 + 20140105 + 99211 - Established Patient Office Or Other Outpatient Visit, Typically 5 Minutes + 25 - Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On + + + + 1 + * Not Available * + * Not Available * + * Not Available * + 11 - Office + 1 - Medical Care + PARTBPROV + + Claim Lines for Claim Number + MyMedicare.gov + 2333444555300 +
+ + + claim Header + 2333444555400 + No Information Available + + + 20140105 + 20140105 + + + $38.00 + $9.38 + $7.50 + $1.88 + + PartB + 9593 + E8889 + claim Header + MyMedicare.gov +
+
Claim Lines for Claim Number
+ 1 + 20140105 + 20140105 + E0601 - Continuous Positive Airway Pressure (Cpap) Device + MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + KX - Requirements Specified In The Medical Policy Have Been Met + + + 1 + $135.00 + $90.45 + $44.55 + 12 - Home + R - Rental of DME + DMEPROVIDR + + Claim Lines for Claim Number + MyMedicare.gov + 11122233310000 +
+ + \ No newline at end of file diff --git a/README.md b/README.md index bea37e4..4eea641 100644 --- a/README.md +++ b/README.md @@ -1,4 +1,64 @@ claims ====== -Exploring JSON representation for claims data \ No newline at end of file +Exploring JSON representation for claims data. + +A sample BlueButton Test file (medicare/medicare_bbp.txt) from MyMedicare.gov has been used to create a medicare_bbp.xml and medicare_bbp.json format. +This has been based on the claims.xml file that was initially created by Ryan Panchadsaram. + +Latest change is to change field names to headlessCamelCase. ie. "Medicare Part B Effective Date" becomes "medicarePartBEffectiveDate". + + +Objective +--------- + +The objective of this work is to: + +1. Create structured file formats in XML and JSON that can be used for the CMS BlueButton Plus data-as-a-service project. +2. Create claims summary and claim detail sections that will also satisfy the needs of the payer community for BlueButton +claims output for beneficiaries of Medicare, Medicaid and private insurance plans. + +Design Principles +----------------- + +The following design principles have been adopted in creating these file formats: + +1. Keep it simple +2. Develop a single file format with the necessary sections incorporated within the file +in order to avoid the challenges that can come with packaging multiple sets of files. + + +# Files in medicare folder: + +## medicare_bbp.txt + +This is a medicare bluebutton test file in simple ASCII format + +## medicare_bbp.xml + +This is an xml version based on the fields in the medicare_bbp.txt file + +## medicare_bbp.json + +This is a json format file that has been generated from the medicare_bbp.xml using an xml to JSON converter at +http://www.freeformatter.com/xml-to-json-converter.html + + +Code conversion from medicare_bbp_v2.txt to medicare_bbp_v2.json by python-bluebutton +(see https://github.com/ekivemark/python-bluebutton + +Code conversion from medicare_bbp_v2.json to medicar_bbp_v2.xml by +http://codebeautify.org/jsontoxml + + +TODO-ekivemark +-------------- + +1. Create a generic BlueButtonPlus.xml and BlueButtonPlus.json that covers medicare and non-medicare payers. +2. Confirm approach in using field within data segments to identify source of data. +3. change field names to remove / +Current Source field Values: + ++ patient ++ mymedicare.gov + diff --git a/claims-working.json b/claims-working.json index 8c47d48..657c443 100644 --- a/claims-working.json +++ b/claims-working.json @@ -3,16 +3,18 @@ "name": "Ellen Harrison Lu", "first_name":"Ellen", "middle_name": "Harrison", - "last_name": "Lu" + "last_name": "Lu", + "patient_identifier":"W1234123456" }, "payer":{ "name":"Name of Insurance", "payer_id":123456, "payer_id_type":"National Payer ID", - "plan_name":"Name of Policy", - "plan_id":123456, + "policy_name":"Name of Policy", + "policy_id":123456, "member_id":"W1234123456", "member_name":"Name of Plan Member", + "plan_name":"Name of Plan", "url":"http://yourinsurer.org" }, "claims":[ diff --git a/claims.json b/claims.json index 1206883..fb45300 100644 --- a/claims.json +++ b/claims.json @@ -1,6 +1,9 @@ { "patient":{ - "name":"Ellen Lu", + "name":"Ellen Harrison Lu", + "first_name":"Ellen", + "middle_name":"Harrison", + "last_name":"Lu", "patient_identifier":"W1234123456" }, "insurance":{ @@ -8,10 +11,11 @@ "payer_id":123456, "payer_id_type":"National Payer ID", "policy_name":"Name of Policy", - "policy_information":123456, + "policy_id":123456, "member_id":"W1234123456", "member_name":"Name of Plan Member", - "plan_name":"Name of Plan" + "plan_name":"Name of Plan", + "url":"http://yourinsurer.org" }, "claims":[ { @@ -29,7 +33,7 @@ }, "charges":{ "price_billed":1022.50, - "negotiated_price":782.33, + "procedure_price":782.33, "insurance_paid":625.86, "patient_responsibility":156.47 }, @@ -53,7 +57,7 @@ "code":5854 } ], - "lines":[ + "details":[ { "start_date":20101102, "end_date":20101102, @@ -66,7 +70,7 @@ ], "quantity":1, "price_billed":275.00, - "negotiated_price":208.99, + "procedure_price":208.99, "patient_responsibility":66.01, "place_of_service_code":41, "place_of_service:":"Ambulance - Land", @@ -87,7 +91,7 @@ ], "quantity":1, "price_billed":275.00, - "negotiated_price":208.99, + "procedure_price":208.99, "patient_responsibility":66.01, "place_of_service_code":41, "place_of_service:":"Ambulance - Land", @@ -108,7 +112,7 @@ ], "quantity":44, "price_billed":472.50, - "negotiated_price":364.35, + "procedure_price":364.35, "patient_responsibility":108.15, "place_of_service_code":41, "place_of_service:":"Ambulance - Land", diff --git a/claims.xml b/claims.xml index 0bf33ef..1d63236 100644 --- a/claims.xml +++ b/claims.xml @@ -5,17 +5,19 @@ Ellen Harrison Lu + W1234123456 - + Name of Insurance 123456 National Payer ID - Name of Policy + Name of Policy 123456 W1234123456 Name of Plan Member + Name of Plan http://yourinsurer.org - + 0210336239290 Part B diff --git a/medicare/medicare_bbp_v2.txt b/medicare/medicare_bbp_v2.txt new file mode 100644 index 0000000..4426c8b --- /dev/null +++ b/medicare/medicare_bbp_v2.txt @@ -0,0 +1,2117 @@ +-------------------------------- +MYMEDICARE.GOV PERSONAL HEALTH INFORMATION + +-------------------------------- +**********CONFIDENTIAL*********** + +Produced by the Blue Button (v2.0) + +02/04/2015 9:18 AM + + + + +-------------------------------- +Demographic + +-------------------------------- + +Source: MyMedicare.gov + + + +Name: JOHN DOE + +Date of Birth: 1/1/1910 + +Address Line 1: 123 ANY ROAD + +Address Line 2: + +City: ANYTOWN + +State: IN + +Zip: 46250 + +Phone Number: 215-248-0684 + +Email: + +Part A Effective Date: 2/1/2014 + +Part B Effective Date: 2/1/2014 + + + +-------------------------------- +Emergency Contact + +-------------------------------- + +Source: Self-Entered + + + +Contact Name: Billy Bigelow2 + +Address Type:Home + +Address Line 1: 1234 Carnival Lane + +Address Line 2: Lobster Bay, ME 11112 + +City: + +State: + +Zip: 11111 + +Relationship: Friend + +Home Phone: + +Work Phone: + +Mobile Phone: + +Email Address: + + + +Contact Name: Enoch Snow + +Address Type:Home + +Address Line 1: 2345 Fish Head Cove + +Address Line 2: Lobster Bay, ME 11112 + +City: + +State: + +Zip: + +Relationship: Friend + +Home Phone: + +Work Phone: + +Mobile Phone: + +Email Address: + + + +-------------------------------- +Self Reported Medical Conditions + +-------------------------------- + +Source: Self-Entered + + + +Condition Name: Allergies + +Medical Condition Start Date: 1/29/2013 + +Medical Condition End Date: + + + +Condition Name: Arthritis + +Medical Condition Start Date: 8/1/1960 + +Medical Condition End Date: 12/31/1980 + + + +Condition Name: Broken Wrist + +Medical Condition Start Date: 2/6/1910 + +Medical Condition End Date: 2/6/2013 + + + +Condition Name: Other + +Medical Condition Start Date: 2/1/2011 + +Medical Condition End Date: + + + +Condition Name: Other + +Medical Condition Start Date: 2/28/2012 + +Medical Condition End Date: + + + +-------------------------------- +Self Reported Allergies + +-------------------------------- + +Source: Self-Entered + + + +Allergy Name: Antibotic + +Type: Drugs + +Reaction: + +Severity: + +Diagnosed: + +Treatment: + +First Episode Date: + +Last Episode Date: + +Last Treatment Date: + +Comments: + + + +Allergy Name: Corn + +Type: Food + +Reaction: Blisters + +Severity: Mild + +Diagnosed: Yes + +Treatment: Other + +First Episode Date: + +Last Episode Date: + +Last Treatment Date: + +Comments: + + + +Allergy Name: Milk + +Type: Food + +Reaction: Anaphylaxis + +Severity: Severe + +Diagnosed: Yes + +Treatment: Epinephrine (Epi-Pen) + +First Episode Date: 3/21/1985 + +Last Episode Date: 3/31/2012 + +Last Treatment Date: 3/31/2012 + +Comments: + + + +Allergy Name: Other - other + +Type: Other - other + +Reaction: + +Severity: + +Diagnosed: + +Treatment: + +First Episode Date: + +Last Episode Date: + +Last Treatment Date: + +Comments: + + + +-------------------------------- +Self Reported Implantable Device + +-------------------------------- + +Source: Self-Entered + + + +Device Name: COronary stent + +Date Implanted: 11/27/2005 + + + +Device Name: Knee replacement + +Date Implanted: 2/2/2014 + + + +Device Name: Pace maker + +Date Implanted: 2/28/2012 + + + +Device Name: foot + +Date Implanted: 9/9/1984 + + + +Device Name: hearing aid + +Date Implanted: 1/1/2013 + + + +Device Name: nov20 + +Date Implanted: 12/15/2007 + + + +-------------------------------- +Self Reported Immunizations + +-------------------------------- + +Source: Self-Entered + + + +Immunization Name: shingles + +Date Administered:2/3/2010 + +Method: Injection + +Were you vaccinated in the US: Yes + +Comments: + +Booster 1 Date: 2/4/2011 + +Booster 2 Date: 4/6/2012 + +Booster 3 Date: + + + +-------------------------------- +Self Reported Labs and Tests + +-------------------------------- + +Source: Self-Entered + + + +Test/Lab Type: Test + +Date Taken: 1/2/2013 + +Administered by: Inova + +Requesting Doctor: Dr. John Doe + +Reason Test/Lab Requested: + +Results: + +Comments: + + + +-------------------------------- +Self Reported Vital Statistics + +-------------------------------- + +Source: Self-Entered + + + +Vital Statistic Type: Glucose + +Date: 2/7/2008 + +Time: 12:00 AM + +Reading/Value: 322 + +Comments: + + + +Vital Statistic Type: Glucose + +Date: 4/3/2009 + +Time: 12:02 PM + +Reading/Value: 24 + +Comments: fwrqwrgreg + + + +Vital Statistic Type: Glucose + +Date: 5/14/2009 + +Time: 12:17 PM + +Reading/Value: 134 + +Comments: rwrtrt + + + +Vital Statistic Type: Otro - other + +Date: 1/1/1939 + +Time: 12:00 AM + +Reading/Value: other + +Comments: + + + +Vital Statistic Type: Pulse + +Date: 4/6/2013 + +Time: 12:00 AM + +Reading/Value: 333 + +Comments: + + + +Vital Statistic Type: Pulse + +Date: 3/2/2011 + +Time: 12:09 AM + +Reading/Value: 80 + +Comments: wwqrgtrt + + + +Vital Statistic Type: Temperature + +Date: 6/5/2009 + +Time: 8:06 AM + +Reading/Value: 100 + +Comments: fwqerqwr + + + +Vital Statistic Type: Temperature + +Date: 4/4/2008 + +Time: 9:02 AM + +Reading/Value: 99 + +Comments: + + + +-------------------------------- +Family Medical History + +-------------------------------- + +Source: Self-Entered + + + +Family Member: Daughter + +Type: Maternal + +DOB:1/1/1994 + +DOD: + +Age: 31 + +Type: Allergy + +Description: Dyes + +Type: Condition + +Description: Diabetes, Type 2 + +Description: Skin Cancer + + +Family Member: Brother + +Type: + +DOB:4/4/2012 + +DOD: + +Age: + +Type: Allergy + +Description: Chemotherapy + +Type: Condition + +Description: Alzheimer's Disease + + +-------------------------------- +Drugs + +-------------------------------- + +Source: Self-Entered + + + +Drug Name: Abacavir TAB 300MG + +Supply: 60 Every 1 Month + +Orig Drug Entry: Abacavir + + + +Drug Name: Abilify Maintena INJ 300MG + +Supply: 1 X Vial Every 1 Month + +Orig Drug Entry: Abilify Maintena + + + +Drug Name: Amlodipine Besylate TAB 10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate + + + +Drug Name: Amlodipine Besylate TAB 2.5MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate + + + +Drug Name: Amlodipine Besylate TAB 5MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-20MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-40MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 10-80MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 5-10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Caduet + + + +Drug Name: Amlodipine Besylate/Atorvastatin Calcium TAB 5-80MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Amlodipine Besylate/Atorvastatin Calcium + + + +Drug Name: Androgel Pump GEL 1.62% + +Supply: 2 X 75GM Pump Bottle (sold in a package of 1 pump bottle) Every 1 Month + +Orig Drug Entry: Androgel Pump + + + +Drug Name: Drospirenone/Ethinyl Estradiol TAB 3-0.03MG + +Supply: 28 Every 1 Month + +Orig Drug Entry: Yasmin 28 + + + +Drug Name: Gabapentin CAP 100MG + +Supply: 90 Every 1 Month + +Orig Drug Entry: Gabapentin + + + +Drug Name: Gabapentin SOL 250/5ML + +Supply: 1 X 470ML Bottle Every 1 Month + +Orig Drug Entry: Gabapentin + + + +Drug Name: Jakafi TAB 10MG + +Supply: 60 Every 1 Month + +Orig Drug Entry: Jakafi + + + +Drug Name: Losartan Potassium/Hydrochlorothiazide TAB 100-25 + +Supply: 30 Every 1 Month + +Orig Drug Entry: Losartan Potassium/Hydrochlorothiazide + + + +Drug Name: Montelukast Sodium TAB 10MG + +Supply: 90 Every 3 Month + +Orig Drug Entry: Montelukast Sodium + + + +Drug Name: Omeprazole CAP 20MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Omeprazole + + + +Drug Name: Rabavert INJ + +Supply: 2 X Vial (sold in a package of 2) Every 12 Month + +Orig Drug Entry: Rabavert + + + +Drug Name: Tabloid TAB 40MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Tabloid + + + +Drug Name: Vagifem TAB 10MCG + +Supply: 8 Every 1 Month + +Orig Drug Entry: Vagifem + + + +Drug Name: Zafirlukast TAB 20MG + +Supply: 60 Every 1 Month + +Orig Drug Entry: Zafirlukast + + + +Drug Name: Zaleplon CAP 10MG + +Supply: 30 Every 1 Month + +Orig Drug Entry: Zaleplon + + + +Drug Name: Zaltrap INJ 100/4ML + +Supply: 1 X 4ML Vial Every 1 Month + +Orig Drug Entry: Zaltrap + + + +-------------------------------- +Preventive Services + +-------------------------------- + +Source: MyMedicare.gov + + + +Description: ABDOMINAL AORTIC ANEURYSM + +Next Eligible Date: 2/1/2014 + +Last Date of Service: + + + +Description: CARDIOVASCULAR + +Next Eligible Date: 2/1/2014 + +Last Date of Service: + + + +Description: PPV + +Next Eligible Date: 2/1/2014 + 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+ +Next Eligible Date: + +Last Date of Service: + + + +Description: SMOKING CESSATION (counseling to stop smoking) + +Next Eligible Date: + +Last Date of Service: + + + +-------------------------------- +Providers + +-------------------------------- + +Source: Self-Entered + + + +Provider Name: ANGELO SCOTTI + +Provider Address: 180 WHITE RD LITTLE SILVER, NJ 07739 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: DOUGLAS KNOX + +Provider Address: 1104 E 23RD ST LAWRENCE, KS 66046 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: SIAMAK RASSADI + +Provider Address: 1331 N 7TH ST PHOENIX, AZ 85006 + +Type: Physician & Other Healthcare Professional + +Specialty: Cardiac Electrophysiology,Cardiovascular Disease (Cardiology) + +Medicare Provider: May Accept Medicare + + + +Provider Name: PETER LEAVITT + +Provider Address: 2965 NECONNERS AVE BEND, OR 97701 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: JOHN KENNEDY + +Provider Address: 8888 KEYSTONE XING INDIANAPOLIS, IN 46240 + +Type: Physician & Other Healthcare Professional + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: REBECCA KELLY + +Provider Address: 7250 CLEARVISTA DR INDIANAPOLIS, IN 46256 + +Type: Physician & Other Healthcare Professional + +Specialty: Addiction Medicine + +Medicare Provider: Yes + + + +Provider Name: RILEY HOSPITAL - PEDS DIALYSIS + +Provider Address: 705 RILEY HOSPITAL DRIVE INDIANAPOLIS, IN 46202 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FMC - SHADELAND STATION + +Provider Address: 7155 SHADELAND STATION STE 130 INDIANAPOLIS, IN 46256 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: IU HEALTH - HOME DIALYSIS + +Provider Address: 8803 N. MERIDIAN ST., STE 150 INDIANAPOLIS, IN 46260 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: MESA VISTA OF BOULDER + +Provider Address: 2121 MESA DRIVE BOULDER, CO 80304 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: FAIRBANKS + +Provider Address: 8102 CLEARVISTA PARKWAY INDIANAPOLIS, IN 46256 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: ALLIANCE HOME HEALTH SERVICES INC + +Provider Address: 9615 N COLLEGE AVE INDIANAPOLIS, IN 46280 + +Type: Home Health + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: THE VIRGINIAN + +Provider Address: 9229 ARLINGTON BLVD FAIRFAX, VA 22031 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: KINDRED TRANSITIONAL CARE & REHAB-ALLISON POINTE + +Provider Address: 5226 E 82ND ST INDIANAPOLIS, IN 46250 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: INDIANA HEART HOSPITAL THE + +Provider Address: 8075 N SHADELAND AVE INDIANAPOLIS, IN 46250 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: COMMUNITY HOSPITAL NORTH + +Provider Address: 7150 CLEARVISTA DR INDIANAPOLIS, IN 46256 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FORUM AT THE CROSSING + +Provider Address: 8505 WOODFIELD CROSSING BLVD INDIANAPOLIS, IN 46240 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: BEAUMONT HOSPITAL, TROY + +Provider Address: 44201 DEQUINDRE ROAD TROY, MI 48085 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: DAVITA - EAGLE HIGHLANDS + +Provider Address: 6925 SHORE TERRACE INDIANAPOLIS, IN 46254 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FMC - CARMEL + +Provider Address: 12400 NORTH MERIDIAN ST., STE 200 CARMEL, IN 46032 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: DSI - NW INDIANAPOLIS RENAL CENTER + +Provider Address: 6488 CORPORATE DRIVE INDIANAPOLIS, IN 46268 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: GEORGE WASHINGTON UNIV HOSPITAL + +Provider Address: 900 23RD ST NW WASHINGTON, DC 20037 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: DAVITA - CARMEL HEALTH AND LIVING + +Provider Address: 118 MEDICAL DRIVE, SUITE 114 CARMEL, IN 46032 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: FMC-INDIANAPOLIS MIDTOWN + +Provider Address: 3007 DR ANDREW J BROWN AVENUE INDIANAPOLIS, IN 46205 + +Type: Dialysis Facility + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: MILLER'S SENIOR LIVING COMMUNITY + +Provider Address: 8400 CLEARVISTA PL INDIANAPOLIS, IN 46256 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: TEST QT + +Provider Address: COEBURN, VA 24230 + +Type: Home Health + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: ADVANCED HOME CARE, INC + +Provider Address: 165 PLAZA ROAD, SUITE 20 WISE, VA 24293 + +Type: Home Health + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: TEST NHC QT + +Provider Address: 0 24230 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: HERITAGE HALL WISE + +Provider Address: 9434 COEBURN MOUNTAIN ROAD WISE, VA 24293 + +Type: Nursing Home + +Specialty: + +Medicare Provider: Yes + + + +Provider Name: QT JAN 15 TEST + +Provider Address: 121 HOME STREET COEBURN, VA 24230 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +Provider Name: NORTON COMMUNITY HOSPITAL + +Provider Address: 100 15TH ST NW NORTON, VA 24273 + +Type: Hospital + +Specialty: + +Medicare Provider: Not Available + + + +-------------------------------- +Pharmacies + +-------------------------------- + +Source: Self-Entered + + + +Pharmacy Name: Castleton Integrative Health 8208 Allisonville Rd Indianapolis, IN 46250 + +Pharmacy Phone: 317-849-1222 + + + +Pharmacy Name: Costco Pharmacy Indianapolis, IN 462506110 East 86th Street Castleton, IN 46250 + +Pharmacy Phone: 317-558-1452 + + + +-------------------------------- +Plans + +-------------------------------- + +Source: MyMedicare.gov + + + +Contract ID/Plan ID: S1111/801 + +Plan Period: 12/01/2012 - current + +Plan Name: + +Marketing Name: + +Plan Address: + +Plan Type: 11 - Medicare Prescription Drug Plan + + + +-------------------------------- +Employer Subsidy + +-------------------------------- + +Source: MyMedicare.gov + + + + +-------------------------------- +Primary Insurance + +-------------------------------- + +Source: MyMedicare.gov + + + + +-------------------------------- +Other Insurance + +-------------------------------- + +Source: MyMedicare.gov + + + +MSP Type: + +Policy Number: 30002 + +Insurer Name: UNITEDHEALTH GROUP + +Insurer Address: 601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034 + +Effective Date: 10/01/1984 + +Termination Date: + + + +-------------------------------- +Claim Summary + +-------------------------------- + +Source: MyMedicare.gov + + + +Claim Number: 11122233330000 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $135.00 + +Medicare Approved: $92.53 + +Provider Paid: $74.02 + +You May be Billed: $18.51 + +Claim Type: DME + +Diagnosis Code 1: 32723 +Diagnosis Code 2: 78051 + +-------------------------------- +Claim Lines for Claim Number: 11122233330000 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: E0601 - Continuous Positive Airway Pressure (Cpap) Device + +Modifier 1/Description: MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + +Modifier 2/Description: KX - Requirements Specified In The Medical Policy Have Been Met + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $135.00 + +Allowed Amount: $92.53 + +Non-Covered: $42.47 + +Place of Service/Description: 12 - Home + +Type of Service/Description: R - Rental of DME + +Rendering Provider No: DMEPROVIDR + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 11122233320000 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $135.00 + +Medicare Approved: $90.45 + +Provider Paid: $72.36 + +You May be Billed: $18.09 + +Claim Type: DME + +Diagnosis Code 1: 32723 +Diagnosis Code 2: 78051 + +-------------------------------- +Claim Lines for Claim Number: 11122233320000 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: E0601 - Continuous Positive Airway Pressure (Cpap) Device + +Modifier 1/Description: MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + +Modifier 2/Description: KX - Requirements Specified In The Medical Policy Have Been Met + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $135.00 + +Allowed Amount: $90.45 + +Non-Covered: $44.55 + +Place of Service/Description: 12 - Home + +Type of Service/Description: R - Rental of DME + +Rendering Provider No: DMEPROVIDR + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555100 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: * Not Available * + +Medicare Approved: * Not Available * + +Provider Paid: * Not Available * + +You May be Billed: * Not Available * + +Claim Type: PartB + +Diagnosis Code 1: 7392 +Diagnosis Code 2: 7241 +Diagnosis Code 3: 7393 +Diagnosis Code 4: 7391 + +-------------------------------- +Claim Lines for Claim Number: 2333444555100 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 98941 - Chiropractic Manipulative Treatment, 3 To 4 Spinal Regions + +Modifier 1/Description: GA - Waiver Of Liability Statement Issued As Required By Payer Policy, Individual Case + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 2 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: G0283 - Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound + +Modifier 1/Description: GY - Item Or Service Statutorily Excluded, Does Not Meet The Definition Of Any Medicare Benefit Or, + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555500 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $1,022.50 + +Medicare Approved: $782.33 + +Provider Paid: $625.86 + +You May be Billed: $156.47 + +Claim Type: PartB + +Diagnosis Code 1: 70700 + +-------------------------------- +Claim Lines for Claim Number: 2333444555500 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls) + +Modifier 1/Description: RH + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $275.00 + +Allowed Amount: $208.99 + +Non-Covered: $66.01 + +Place of Service/Description: 41 - Ambulance - Land + +Type of Service/Description: 9 - Other Medical Services + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 2 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: A0428 - Ambulance Service, Basic Life Support, Non-Emergency Transport, (Bls) + +Modifier 1/Description: HR - Family/Couple With Client Present + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $275.00 + +Allowed Amount: $208.99 + +Non-Covered: $66.01 + +Place of Service/Description: 41 - Ambulance - Land + +Type of Service/Description: 9 - Other Medical Services + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 3 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: A0425 - Ground Mileage, Per Statute Mile + +Modifier 1/Description: RH + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 44 + +Submitted Amount/Charges: $472.50 + +Allowed Amount: $364.35 + +Non-Covered: $108.15 + +Place of Service/Description: 41 - Ambulance - Land + +Type of Service/Description: 9 - Other Medical Services + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555200 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: * Not Available * + +Medicare Approved: * Not Available * + +Provider Paid: * Not Available * + +You May be Billed: * Not Available * + +Claim Type: PartB + +Diagnosis Code 1: 2163 + +-------------------------------- +Claim Lines for Claim Number: 2333444555200 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 99213 - Established Patient Office Or Other Outpatient Visit, Typically 15 Minutes + +Modifier 1/Description: + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 22 - Outpatient Hospital + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555300 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: * Not Available * + +Medicare Approved: * Not Available * + +Provider Paid: * Not Available * + +You May be Billed: * Not Available * + +Claim Type: PartB + +Diagnosis Code 1: 28521 +Diagnosis Code 2: 5854 + +-------------------------------- +Claim Lines for Claim Number: 2333444555300 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: J2916 - Injection, Sodium Ferric Gluconate Complex In Sucrose Injection, 12.5 Mg + +Modifier 1/Description: + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 10 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 2 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 36000 - Insertion Of Needle Or Catheter Into A Vein + +Modifier 1/Description: + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 2 - Surgery + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 3 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 90765 - Intravenous Infusion, For Therapy, Prophylaxis, Or Diagnosis (Specify Substance Or Drug); In + +Modifier 1/Description: + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 4 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 90775 - Therapeutic, Prophylactic Or Diagnostic Injection (Specify Substance Or Drug); Each Addition + +Modifier 1/Description: + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Line number: 5 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 99211 - Established Patient Office Or Other Outpatient Visit, Typically 5 Minutes + +Modifier 1/Description: 25 - Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: * Not Available * + +Allowed Amount: * Not Available * + +Non-Covered: * Not Available * + +Place of Service/Description: 11 - Office + +Type of Service/Description: 1 - Medical Care + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +-------------------------------- + + + +-------------------------------- + + + +Claim Number: 2333444555400 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $38.00 + +Medicare Approved: $9.38 + +Provider Paid: $7.50 + +You May be Billed: $1.88 + +Claim Type: PartB + +Diagnosis Code 1: 9593 +Diagnosis Code 2: E8889 + +-------------------------------- +Claim Lines for Claim Number: 2333444555400 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: 73110 - X-Ray Of Wrist, Minimum Of 3 Views + +Modifier 1/Description: 26 - Professional Component: Certain Procedures Are A Combination Of A Physician Component And A Tec + +Modifier 2/Description: + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $38.00 + +Allowed Amount: $9.38 + +Non-Covered: $28.62 + +Place of Service/Description: 22 - Outpatient Hospital + +Type of Service/Description: 4 - Diagnostic x-ray + +Rendering Provider No: PARTBPROV + +Rendering Provider NPI: + + + +Claim Number: 11122233310000 + +Provider: No Information Available + +Provider Billing Address: + +Service Start Date: 01/05/2014 + +Service End Date: 01/05/2014 + +Amount Charged: $135.00 + +Medicare Approved: $90.45 + +Provider Paid: $72.36 + +You May be Billed: $18.09 + +Claim Type: DME + +Diagnosis Code 1: 32723 +Diagnosis Code 2: 78051 + +-------------------------------- +Claim Lines for Claim Number: 11122233310000 + +-------------------------------- + + + +Line number: 1 + +Date of Service From: 01/05/2014 + +Date of Service To: 01/05/2014 + +Procedure Code/Description: E0601 - Continuous Positive Airway Pressure (Cpap) Device + +Modifier 1/Description: MS - Six Month Maintenance And Servicing Fee For Reasonable And Necessary Parts And Labor Which Are + +Modifier 2/Description: KX - Requirements Specified In The Medical Policy Have Been Met + +Modifier 3/Description: + +Modifier 4/Description: + +Quantity Billed/Units: 1 + +Submitted Amount/Charges: $135.00 + +Allowed Amount: $90.45 + +Non-Covered: $44.55 + +Place of Service/Description: 12 - Home + +Type of Service/Description: R - Rental of DME + +Rendering Provider No: DMEPROVIDR + +Rendering Provider NPI: + + + diff --git a/sample/medicare.json b/sample/medicare.json deleted file mode 100644 index ada63c9..0000000 --- a/sample/medicare.json +++ /dev/null @@ -1,294 +0,0 @@ -{ - "patient":{ - "name":"John Doe", - "birthday":19100101, - "address":{ - "line1": "8115 Knue Road", - "line2": "Mailpoint INA1-AF-16", - "city": "Indianapolis", - "state": "IN", - "zip": 46250 - }, - "homePhone":"215-555-0684", - "emailAddress": "test_user_fh@gmail.com" - }, - "medicare":{ - "partAEffectiveDate": 19850103, - "partBEffectiveDate": 19850104 - }, - "claims":[ - { - "claim":"0210336239290", - "type":"PartB", - "provider":{ - "name":"Inova Health Services", - "providerID":123456789, - "providerIDType":"National Provider ID" - }, - "date":{ - "lowValue":20101102, - "highValue":20101102 - }, - "charges":{ - "priceBilled":1022.50, - "negotiatedPrice":782.33, - "insurancePaid":625.86, - "patientResponsibility":156.47 - }, - "diagnosis":[ - { - "name":"Pressure ulcer, unspecified site (Pressure ulcer, site NOS)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"70700" - } - ] - }, - { - "claim":"1410019001810", - "type":"PartB", - "provider":{ - "name":"Inova Health Services", - "providerID":123456789, - "providerIDType":"National Provider ID" - }, - "date":{ - "lowValue":20101001, - "highValue":20101001 - }, - "charges":{ - "priceBilled":354.25, - "negotiatedPrice":0.00, - "insurancePaid":0.00, - "patientResponsibility":0.00 - }, - "diagnosis":[ - { - "name":"Anemia in chronic kidney disease (Anemia in chr kidney dis)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"28521" - }, - { - "name":"Chronic kidney disease, Stage IV (severe) (Chr kidney dis stage IV)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"5854" - } - ] - }, - { - "claim":"0210020056080", - "type":"PartB", - "provider":{ - "name":"Inova Health Services", - "providerID":123456789, - "providerIDType":"National Provider ID" - }, - "date":{ - "lowValue":20101001, - "highValue":20101001 - }, - "charges":{ - "priceBilled":38.00, - "negotiatedPrice":9.38, - "insurancePaid":7.50, - "patientResponsibility":1.88 - }, - "diagnosis":[ - { - "name":"Elbow, forearm, and wrist injury (Elb/forearm/wrst inj NOS)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"9593" - }, - { - "name":"Unspecified fall (Fall NOS)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"E8889" - } - ] - }, - { - "claim":"1110008250730", - "type":"PartB", - "provider":{ - "name":"Inova Health Services", - "providerID":123456789, - "providerIDType":"National Provider ID" - }, - "date":{ - "lowValue":20101001, - "highValue":20101001 - }, - "charges":{ - "priceBilled":42.00, - "negotiatedPrice":0.00, - "insurancePaid":0.00, - "patientResponsibility":0.00 - }, - "diagnosis":[ - { - "name":"Nonallopathic lesions, thoracic region (Somat dysfunc thorac reg)", - 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} - ] - }, - { - "claim":"21001400340202MAA", - "type":"Inpatient", - "provider":{ - "name":"Inova Health Services", - "providerID":123456789, - "providerIDType":"National Provider ID" - }, - "date":{ - "lowValue":20101001, - "highValue":20101001 - }, - "charges":{ - "priceBilled":456.00, - "negotiatedPrice":456.00, - "insurancePaid":0.00, - "patientResponsibility":0.00 - }, - "diagnosis":[ - { - "name":"Aftercare following surgery for neoplasm (Aftercare neoplasm surg)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"V5842" - }, - { - "name":"Malignant neoplasm of colon, unspecified site (Malignant neo colon NOS)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"1539" - }, - { - "name":"Congestive heart failure, unspecified (CHF NOS)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"4280" - }, - { - "name":"Coronary atherosclerosis of unspecified type of vessel, native or graft (Cor ath unsp vsl ntv/gft)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"41400" - } - ] - }, - { - "claim":"2210019297820", - "type":"PartB", - "provider":{ - "name":"Inova Health Services", - "providerID":123456789, - "providerIDType":"National Provider ID" - }, - "date":{ - "lowValue":20101001, - "highValue":20101001 - }, - "charges":{ - "priceBilled":133.00, - "negotiatedPrice":0.00, - "insurancePaid":0.00, - "patientResponsibility":0.00 - }, - "diagnosis":[ - { - "name":"Benign neoplasm of skin of other and unspecified parts of face (Benign neo skin face NEC)", - "codeSystemName":"ICD-9", - "codeSystem":"2.16.840.1.113883.6.104", - "code":"2163" - } - ] - } - ] -} \ No newline at end of file