Generated Narrative: Bundle PCT-GFE-Bundle-Prof-1

Bundle PCT-GFE-Bundle-Prof-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-MRI

Resource Claim:

Generated Narrative: Claim PCT-GFE-Summary-MRI

status: Active

type: Estimate Summary

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

billablePeriod: 2021-10-31 --> (ongoing)

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: ??

priority: Normal

Diagnoses

-	Sequence	Diagnosis[x]	Type
*	1	Unspecified focal traumatic brain injury	Principal Diagnosis

Insurances

-	Sequence	Focal	Coverage
*	1	true	Coverage: extension = No display for Extension ,No display for Extension ; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

Totals

-	Value	Currency
*	200	USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI

Resource Claim:

Generated Narrative: Claim PCT-GFE-Professional-MRI

identifier: Placer Identifier/GFEProviderAssignedID0002

status: Active

type: Professional

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: Practitioner Nora Ologist

priority: Normal

Payees

-	Type
*	Provider

referral: Referral Number

Diagnoses

-	Sequence	Diagnosis[x]	Type
*	1	Unspecified focal traumatic brain injury	Principal Diagnosis

Insurances

-	Sequence	Focal	Coverage
*	1	true	Coverage: extension = No display for Extension ,No display for Extension ; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

item

sequence: 1

productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

serviced: 2021-10-31

location: Inpatient Hospital

quantity: 1

UnitPrices

-	Value	Currency
*	200	USD

Nets

-	Value	Currency
*	200	USD

Totals

-	Value	Currency
*	200	USD

Entry 3 - fullUrl = http://example.org/fhir/Practitioner/Submitter-Practitioner-1

Resource Practitioner:

Generated Narrative: Practitioner Submitter-Practitioner-1

identifier: National provider identifier/6456789016, Electronic Transmitter Identification Number/ETIN-20020001

active: true

name: Nora Ologist

telecom: ph: 860-547-3301(Work), csender@GFEServiceHelp.com

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

Resource Organization "org1001"

Profile: PCT Organization

identifier: Electronic Transmitter Identification Number/ETIN-3200002

active: true

type: Payer ​(Organization type#pay)

name: Umbrella Insurance Company

telecom: ph: 860-547-5001(WORK)

address: 680 Asylum Street Hartford CT 06155 US

Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

Eve Betterhalf female, DoB: 1955-07-23 ( http://example.com/identifiers/patient/1001)

---

Marital Status:	unmarried
Contact Details:	ph: 781-949-4949(MOBILE) 222 Burlington Road, Bedford MA 01730
Language:	English (United States) (preferred)

Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

Resource Coverage "coverage1001"

Profile: PCT Coverage

Extension Definition for Coverage.kind for Version 5.0: insurance

status: active

subscriberId: PFP123450000

beneficiary: Patient/patient1001 " BETTERHALF"

relationship: Self ​(SubscriberPolicyholder Relationship Codes#self)

period: 2021-01-01 --> 2022-01-01

payor: Organization/org1001 "Umbrella Insurance Company"

Classes

-	Type	Value	Name
*	Plan ​(Coverage Class Codes#plan)	Premim Family Plus	Premim Family Plus Plan

CostToBeneficiaries

-	Type	Value[x]
*	Copay Percentage ​(Coverage Copay Type Codes#copaypct)	20