Generated Narrative: ExplanationOfBenefit

Snapshot Age In Years: 27

identifier: Source System Row Identifier: 000000000000000000019721078x2(use: OFFICIAL)

status: active

type: Pharmacy; Pharmacy claims for goods and services (Payer Claim Type Codes#pharmacy; local-claim-type#Pharmacy)

use: claim

patient: Patient/CDMPatientInstance " MCLASTNAME"

created: 2017-07-25 05:31:00-0500

insurer:

provider: Practitioner/DrKelly " KELLY"

priority: Normal (Process Priority Codes#normal)

outcome: complete

CareTeams

supportingInfo

sequence: 1

category: Day Supply (Claim Supporting Info Category Codes#dayssupply)

value: 28

supportingInfo

sequence: 2

category: Information (Claim Information Category Codes#info)

code: 0 (NCPDP Dispense As Written Codes#0)

supportingInfo

sequence: 3

category: Information (Claim Information Category Codes#info)

code: Refill number (Claim Supporting Info Type Codes#refill-number)

value: 1

supportingInfo

sequence: 4

category: Information (Claim Information Category Codes#info)

code: Retail (Rx Mail Or Retail Codes#r)

Insurances

item

Capitated Service Indicator: N

Average Wholesale Price: US$2.88 (USD)

sequence: 1

careTeamSequence: 1

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

serviced: 2017-06-18

location: Pharmacy (CMS Place of Service Codes (POS)#01; local-place-of-service#LocalPlcOfService)

quantity: 4 metric

adjudication

category: Coinsurance (Adjudication Category Codes#coinsurance)

Amounts

-	Value	Currency
*	0.48	USD

adjudication

category: Copayment (Adjudication Category Codes#copay)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Deductible Amount (Adjudication Category Codes#deductible)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Third Party Amount (Adjudication Category Codes#third-party)

Amounts

-	Value	Currency
*	0	USD

adjudication

category: Allowed Amount (Adjudication Category Codes#allowed)

Amounts

-	Value	Currency
*	1.59	USD

adjudication

category: Net Payment (Adjudication Category Codes#net-payment)

Amounts

-	Value	Currency
*	1.11	USD

detail

Claim Item Detail Classification: Dispensing Fee (Claim Item Detail Classification Codes#dispensing-fee)

sequence: 1

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

UnitPrices

-	Value	Currency
*	0.45	USD

detail

Claim Item Detail Classification: Ingredient Cost (Claim Item Detail Classification Codes#ingredient-cost)

sequence: 2

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

UnitPrices

-	Value	Currency
*	1.14	USD

detail

Claim Item Detail Classification: Sales Tax (Claim Item Detail Classification Codes#sales-tax)

sequence: 3

productOrService: 69452-0151-20 (NDC No Hyphens Codes#69452015120)

UnitPrices

-	Value	Currency
*	0	USD

Adjudications