Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot United States of America flag

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

: PCT-GFE-Collection-Bundle-1 - XML Representation

Raw xml | Download



<Bundle xmlns="http://hl7.org/fhir">
  <id value="PCT-GFE-Collection-Bundle-1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-collection-bundle"/>
  </meta>
  <identifier>
    <system value="http://example.com/identifiers/bundle"/>
    <value value="59688475-2324-3242-2347384711"/>
  </identifier>
  <type value="collection"/>
  <timestamp value="2024-03-29T11:01:00+05:00"/>
  <entry id="patient1001">
    <fullUrl value="http://example.org/fhir/Patient/patient1001"/>
    <resource>
      <Patient>
        <id value="patient1001"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
        </text>
        <identifier>
          <system value="http://example.com/identifiers/patient"/>
          <value value="1001"/>
        </identifier>
        <name>
          <text value="Eve Betterhalf"/>
          <family value="Betterhalf"/>
          <given value="Eve"/>
        </name>
        <telecom>
          <system value="phone"/>
          <value value="781-949-4949"/>
          <use value="mobile"/>
        </telecom>
        <gender value="female"/>
        <birthDate value="1955-07-23"/>
        <address>
          <text value="222 Burlington Road, Bedford MA 01730"/>
        </address>
        <maritalStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
            <code value="U"/>
            <display value="unmarried"/>
          </coding>
        </maritalStatus>
        <communication>
          <language>
            <coding>
              <system value="urn:ietf:bcp:47"/>
              <code value="en-US"/>
              <display value="English (United States)"/>
            </coding>
          </language>
          <preferred value="true"/>
        </communication>
      </Patient>
    </resource>
  </entry>
  <entry id="coverage1001">
    <fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
    <resource>
      <Coverage>
        <id value="coverage1001"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="coverage1001"></a><a name="hccoverage1001"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Coverage &quot;coverage1001&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --&gt; 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td>Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Copay Percentage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>
        </text>
        <extension
                   url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
          <valueCode value="insurance"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
          <valueBoolean value="false"/>
        </extension>
        <status value="active"/>
        <subscriberId value="PFP123450000"/>
        <beneficiary>🔗 
          <reference value="Patient/patient1001"/>
        </beneficiary>
        <relationship>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
            <code value="self"/>
            <display value="Self"/>
          </coding>
        </relationship>
        <period>
          <start value="2021-01-01"/>
          <end value="2022-01-01"/>
        </period>
        <payor>🔗 
          <reference value="Organization/org1001"/>
        </payor>
        <class>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
              <code value="plan"/>
              <display value="Plan"/>
            </coding>
          </type>
          <value value="Premim Family Plus"/>
          <name value="Premim Family Plus Plan"/>
        </class>
        <costToBeneficiary>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
              <code value="copaypct"/>
              <display value="Copay Percentage"/>
            </coding>
          </type>
          <valueQuantity>
            <value value="20"/>
          </valueQuantity>
        </costToBeneficiary>
      </Coverage>
    </resource>
  </entry>
  <entry id="Submitter-Org-1">
    <fullUrl value="http://example.org/fhir/Organization/Submitter-Org-1"/>
    <resource>
      <Organization>
        <id value="Submitter-Org-1"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="Submitter-Org-1"></a><a name="hcSubmitter-Org-1"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization &quot;Submitter-Org-1&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-10010301</p><p><b>active</b>: true</p><p><b>type</b>: Non-Healthcare Business or Corporation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#bus)</span></p><p><b>name</b>: GFE Service Help INC.</p><h3>Contacts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Purpose</b></td><td><b>Name</b></td><td><b>Telecom</b></td></tr><tr><td style="display: none">*</td><td>GFE-related <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTOrgContactPurposeType.html">PCT Organization Contact Purpose Type Code System</a>#GFERELATED)</span></td><td>Clara Sender</td><td>ph: 781-632-3209(WORK), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></td></tr></table></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
              <code value="ETIN"/>
            </coding>
          </type>
          <value value="ETIN-10010301"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/organization-type"/>
            <code value="bus"/>
          </coding>
        </type>
        <name value="GFE Service Help INC."/>
        <contact>
          <purpose>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType"/>
              <code value="GFERELATED"/>
            </coding>
          </purpose>
          <name>
            <text value="Clara Sender"/>
          </name>
          <telecom>
            <system value="phone"/>
            <value value="781-632-3209"/>
            <use value="work"/>
          </telecom>
          <telecom>
            <system value="email"/>
            <value value="csender@GFEServiceHelp.com"/>
            <use value="work"/>
          </telecom>
        </contact>
      </Organization>
    </resource>
  </entry>
  <entry id="org1001">
    <fullUrl value="http://example.org/fhir/Organization/org1001"/>
    <resource>
      <Organization>
        <id value="org1001"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
        </meta>
        <text>
          <status value="additional"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1001"></a><a name="hcorg1001"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization &quot;org1001&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US</p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
              <code value="ETIN"/>
            </coding>
          </type>
          <value value="ETIN-3200002"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/organization-type"/>
            <code value="pay"/>
            <display value="Payer"/>
          </coding>
        </type>
        <name value="Umbrella Insurance Company"/>
        <telecom>
          <system value="phone"/>
          <value value="860-547-5001"/>
          <use value="work"/>
        </telecom>
        <address>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
            <valueCoding>
              <system value="urn:iso:std:iso:3166:-2"/>
              <code value="US-CT"/>
            </valueCoding>
          </extension>
          <line value="680 Asylum Street"/>
          <city value="Hartford"/>
          <state value="CT"/>
          <postalCode value="06155"/>
          <country value="US"/>
        </address>
      </Organization>
    </resource>
  </entry>
  <entry id="PCT-GFE-Bundle-Inst-1">
    <fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1"/>
    <resource>
      <Bundle>
        <id value="PCT-GFE-Bundle-Inst-1"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
        </meta>
        <identifier>
          <system value="http://example.com/identifiers/bundle"/>
          <value value="59688475-2324-3242-23473847"/>
        </identifier>
        <type value="collection"/>
        <timestamp value="2021-11-09T11:01:00+05:00"/>
        <entry id="PCT-GFE-Summary-1">
          <fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Summary-1"/>
          <resource>
            <Claim>
              <id value="PCT-GFE-Summary-1"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="PCT-GFE-Summary-1"></a><a name="hcPCT-GFE-Summary-1"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Claim &quot;PCT-GFE-Summary-1&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-gfe-summary.html">PCT Good Faith Estimate Summary</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Estimate Summary <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTEstimateTypeSummaryCSTemporaryTrialUse.html">PCT Estimate Type Code System</a>#estimate-summary)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>billablePeriod</b>: 2021-10-31 --&gt; 2021-10-31</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <span>??</span></p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><h3>Totals</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></div>
              </text>
              <status value="active"/>
              <type>
                <coding>
                  <system
                          value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
                  <code value="estimate-summary"/>
                  <display value="Estimate Summary"/>
                </coding>
              </type>
              <use value="predetermination"/>
              <patient>🔗 
                <reference value="Patient/patient1001"/>
              </patient>
              <billablePeriod>
                <start value="2021-10-31"/>
                <end value="2021-10-31"/>
              </billablePeriod>
              <created value="2021-10-05"/>
              <insurer>🔗 
                <reference value="Organization/org1001"/>
              </insurer>
              <provider>
                <extension
                           url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
                  <valueCode value="not-applicable"/>
                </extension>
              </provider>
              <priority>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/processpriority"/>
                  <code value="normal"/>
                </coding>
              </priority>
              <diagnosis>
                <sequence value="1"/>
                <diagnosisCodeableConcept>
                  <coding>
                    <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
                    <code value="S06.30"/>
                    <display
                             value="Unspecified focal traumatic brain injury"/>
                  </coding>
                </diagnosisCodeableConcept>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
                    <code value="principal"/>
                  </coding>
                </type>
                <packageCode>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
                    <code value="400"/>
                    <display value="Head trauma - concussion"/>
                  </coding>
                </packageCode>
              </diagnosis>
              <insurance>
                <sequence value="1"/>
                <focal value="true"/>
                <coverage>🔗 
                  <reference value="Coverage/coverage1001"/>
                </coverage>
              </insurance>
              <total>
                <value value="200"/>
                <currency value="USD"/>
              </total>
            </Claim>
          </resource>
        </entry>
        <entry id="PCT-GFE-Institutional-1">
          <fullUrl
                   value="http://example.org/fhir/Claim/PCT-GFE-Institutional-1"/>
          <resource>
            <Claim>
              <id value="PCT-GFE-Institutional-1"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="PCT-GFE-Institutional-1"></a><a name="hcPCT-GFE-Institutional-1"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Claim &quot;PCT-GFE-Institutional-1&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-gfe-institutional.html">PCT Good Faith Estimate Institutional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1021</p><p><b>GFEDisclaimer</b>: For estimation purposes only</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008001</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2021-10-31</p></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <a href="Organization-Submitter-Org-1.html">Organization/Submitter-Org-1</a> &quot;GFE Service Help INC.&quot;</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html">Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Type of Bill <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTSupportingInfoType.html">PCT GFE Supporting Info Type Code System</a>#typeofbill)</span></td><td>Hospital Inpatient (Part A) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCTypeOfBill.html">AHA NUBC Type Of Bill Codes</a>#011X)</span></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</p><p><b>sequence</b>: 1</p><p><b>revenue</b>: Magnetic Resonance Technology (MRT) - Brain/brain stem <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCRevenueCodes.html">AHA NUBC Revenue Codes</a>#0611)</span></p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>modifier</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>serviced</b>: 2021-10-31</p><p><b>quantity</b>: 1</p><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></blockquote><h3>Totals</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></div>
              </text>
              <extension
                         url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
                <valueString value="EEMM1021"/>
              </extension>
              <extension
                         url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer">
                <valueString value="For estimation purposes only"/>
              </extension>
              <extension
                         url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
                <extension url="linkingIdentifier">
                  <valueString value="223452-2342-2435-008001"/>
                </extension>
                <extension url="plannedPeriodOfService">
                  <valueDate value="2021-10-31"/>
                </extension>
              </extension>
              <identifier>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                    <code value="PLAC"/>
                    <display value="Placer Identifier"/>
                  </coding>
                </type>
                <system
                        value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                <value value="GFEProviderAssignedID0001"/>
              </identifier>
              <status value="active"/>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/claim-type"/>
                  <code value="institutional"/>
                  <display value="Institutional"/>
                </coding>
              </type>
              <use value="predetermination"/>
              <patient>🔗 
                <reference value="Patient/patient1001"/>
              </patient>
              <created value="2021-10-05"/>
              <insurer>🔗 
                <reference value="Organization/org1001"/>
              </insurer>
              <provider>🔗 
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
                  <valueCodeableConcept>
                    <coding>
                      <system value="http://nucc.org/provider-taxonomy"/>
                      <code value="2085D0003X"/>
                      <display
                               value="Diagnostic Neuroimaging (Radiology) Physician"/>
                    </coding>
                  </valueCodeableConcept>
                </extension>
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling">
                  <valueBoolean value="true"/>
                </extension>
                <reference value="Organization/Submitter-Org-1"/>
              </provider>
              <priority>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/processpriority"/>
                  <code value="normal"/>
                </coding>
              </priority>
              <payee>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                    <code value="provider"/>
                  </coding>
                </type>
              </payee>
              <referral>
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
                  <valueString value="REF12022002-121"/>
                </extension>
                <display value="Referral Number"/>
              </referral>
              <supportingInfo>
                <sequence value="1"/>
                <category>
                  <coding>
                    <system
                            value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType"/>
                    <code value="typeofbill"/>
                  </coding>
                </category>
                <code>
                  <coding>
                    <system
                            value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
                    <code value="011X"/>
                    <display value="Hospital Inpatient (Part A)"/>
                  </coding>
                </code>
              </supportingInfo>
              <diagnosis>
                <sequence value="1"/>
                <diagnosisCodeableConcept>
                  <coding>
                    <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
                    <code value="S06.30"/>
                    <display
                             value="Unspecified focal traumatic brain injury"/>
                  </coding>
                </diagnosisCodeableConcept>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
                    <code value="principal"/>
                  </coding>
                </type>
                <packageCode>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
                    <code value="400"/>
                    <display value="Head trauma - concussion"/>
                  </coding>
                </packageCode>
              </diagnosis>
              <insurance>
                <sequence value="1"/>
                <focal value="true"/>
                <coverage>🔗 
                  <reference value="Coverage/coverage1001"/>
                </coverage>
              </insurance>
              <item>
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
                  <valueString value="Imaging"/>
                </extension>
                <sequence value="1"/>
                <revenue>
                  <coding>
                    <system
                            value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
                    <code value="0611"/>
                    <display
                             value="Magnetic Resonance Technology (MRT) - Brain/brain stem"/>
                  </coding>
                </revenue>
                <productOrService>
                  <coding>
                    <system value="http://www.ama-assn.org/go/cpt"/>
                    <code value="70551"/>
                    <display
                             value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
                  </coding>
                </productOrService>
                <modifier>
                  <coding>
                    <system value="http://www.ama-assn.org/go/cpt"/>
                    <code value="70551"/>
                    <display
                             value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
                  </coding>
                </modifier>
                <servicedDate value="2021-10-31"/>
                <quantity>
                  <value value="1"/>
                </quantity>
                <net>
                  <value value="200"/>
                  <currency value="USD"/>
                </net>
              </item>
              <total>
                <value value="200"/>
                <currency value="USD"/>
              </total>
            </Claim>
          </resource>
        </entry>
        <entry id="Submitter-Org-1">
          <fullUrl
                   value="http://example.org/fhir/Organization/Submitter-Org-1"/>
          <resource>
            <Organization>
              <id value="Submitter-Org-1"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="Submitter-Org-1"></a><a name="hcSubmitter-Org-1"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization &quot;Submitter-Org-1&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-10010301</p><p><b>active</b>: true</p><p><b>type</b>: Non-Healthcare Business or Corporation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#bus)</span></p><p><b>name</b>: GFE Service Help INC.</p><h3>Contacts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Purpose</b></td><td><b>Name</b></td><td><b>Telecom</b></td></tr><tr><td style="display: none">*</td><td>GFE-related <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTOrgContactPurposeType.html">PCT Organization Contact Purpose Type Code System</a>#GFERELATED)</span></td><td>Clara Sender</td><td>ph: 781-632-3209(WORK), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></td></tr></table></div>
              </text>
              <identifier>
                <type>
                  <coding>
                    <system
                            value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
                    <code value="ETIN"/>
                  </coding>
                </type>
                <value value="ETIN-10010301"/>
              </identifier>
              <active value="true"/>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/organization-type"/>
                  <code value="bus"/>
                </coding>
              </type>
              <name value="GFE Service Help INC."/>
              <contact>
                <purpose>
                  <coding>
                    <system
                            value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType"/>
                    <code value="GFERELATED"/>
                  </coding>
                </purpose>
                <name>
                  <text value="Clara Sender"/>
                </name>
                <telecom>
                  <system value="phone"/>
                  <value value="781-632-3209"/>
                  <use value="work"/>
                </telecom>
                <telecom>
                  <system value="email"/>
                  <value value="csender@GFEServiceHelp.com"/>
                  <use value="work"/>
                </telecom>
              </contact>
            </Organization>
          </resource>
        </entry>
        <entry id="org1001">
          <fullUrl value="http://example.org/fhir/Organization/org1001"/>
          <resource>
            <Organization>
              <id value="org1001"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1001"></a><a name="hcorg1001"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization &quot;org1001&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US</p></div>
              </text>
              <identifier>
                <type>
                  <coding>
                    <system
                            value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
                    <code value="ETIN"/>
                  </coding>
                </type>
                <value value="ETIN-3200002"/>
              </identifier>
              <active value="true"/>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/organization-type"/>
                  <code value="pay"/>
                  <display value="Payer"/>
                </coding>
              </type>
              <name value="Umbrella Insurance Company"/>
              <telecom>
                <system value="phone"/>
                <value value="860-547-5001"/>
                <use value="work"/>
              </telecom>
              <address>
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
                  <valueCoding>
                    <system value="urn:iso:std:iso:3166:-2"/>
                    <code value="US-CT"/>
                  </valueCoding>
                </extension>
                <line value="680 Asylum Street"/>
                <city value="Hartford"/>
                <state value="CT"/>
                <postalCode value="06155"/>
                <country value="US"/>
              </address>
            </Organization>
          </resource>
        </entry>
        <entry id="patient1001">
          <fullUrl value="http://example.org/fhir/Patient/patient1001"/>
          <resource>
            <Patient>
              <id value="patient1001"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
              </text>
              <identifier>
                <system value="http://example.com/identifiers/patient"/>
                <value value="1001"/>
              </identifier>
              <name>
                <text value="Eve Betterhalf"/>
                <family value="Betterhalf"/>
                <given value="Eve"/>
              </name>
              <telecom>
                <system value="phone"/>
                <value value="781-949-4949"/>
                <use value="mobile"/>
              </telecom>
              <gender value="female"/>
              <birthDate value="1955-07-23"/>
              <address>
                <text value="222 Burlington Road, Bedford MA 01730"/>
              </address>
              <maritalStatus>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
                  <code value="U"/>
                  <display value="unmarried"/>
                </coding>
              </maritalStatus>
              <communication>
                <language>
                  <coding>
                    <system value="urn:ietf:bcp:47"/>
                    <code value="en-US"/>
                    <display value="English (United States)"/>
                  </coding>
                </language>
                <preferred value="true"/>
              </communication>
            </Patient>
          </resource>
        </entry>
        <entry>
          <fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
          <resource>
            <Coverage>
              <id value="coverage1001"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="coverage1001"></a><a name="hccoverage1001"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Coverage &quot;coverage1001&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --&gt; 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td>Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Copay Percentage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>
              </text>
              <extension
                         url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
                <valueCode value="insurance"/>
              </extension>
              <extension
                         url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
                <valueBoolean value="false"/>
              </extension>
              <status value="active"/>
              <subscriberId value="PFP123450000"/>
              <beneficiary>🔗 
                <reference value="Patient/patient1001"/>
              </beneficiary>
              <relationship>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
                  <code value="self"/>
                  <display value="Self"/>
                </coding>
              </relationship>
              <period>
                <start value="2021-01-01"/>
                <end value="2022-01-01"/>
              </period>
              <payor>🔗 
                <reference value="Organization/org1001"/>
              </payor>
              <class>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                    <code value="plan"/>
                    <display value="Plan"/>
                  </coding>
                </type>
                <value value="Premim Family Plus"/>
                <name value="Premim Family Plus Plan"/>
              </class>
              <costToBeneficiary>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
                    <code value="copaypct"/>
                    <display value="Copay Percentage"/>
                  </coding>
                </type>
                <valueQuantity>
                  <value value="20"/>
                </valueQuantity>
              </costToBeneficiary>
            </Coverage>
          </resource>
        </entry>
      </Bundle>
    </resource>
  </entry>
  <entry id="PCT-GFE-Missing-Bundle-1">
    <fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1"/>
    <resource>
      <Bundle>
        <id value="PCT-GFE-Missing-Bundle-1"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle"/>
        </meta>
        <type value="collection"/>
        <timestamp value="2024-03-27T11:01:00+05:00"/>
        <entry id="org1002">
          <fullUrl value="http://example.org/fhir/Organization/org1002"/>
          <resource>
            <Organization>
              <id value="org1002"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1002"></a><a name="hcorg1002"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization &quot;org1002&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: National provider identifier/1234568095, Tax ID number/TAX-3211001</p><p><b>active</b>: true</p><p><b>type</b>: Healthcare Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#prov)</span></p><p><b>name</b>: Boston Radiology Center</p><p><b>telecom</b>: ph: 781-232-3200(WORK)</p><p><b>address</b>: 32 Fruit Street Boston MA 02114 US</p></div>
              </text>
              <identifier>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                    <code value="NPI"/>
                  </coding>
                </type>
                <system value="http://hl7.org/fhir/sid/us-npi"/>
                <value value="1234568095"/>
              </identifier>
              <identifier>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                    <code value="TAX"/>
                  </coding>
                </type>
                <system value="urn:oid:2.16.840.1.113883.4.4"/>
                <value value="TAX-3211001"/>
              </identifier>
              <active value="true"/>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/organization-type"/>
                  <code value="prov"/>
                  <display value="Healthcare Provider"/>
                </coding>
              </type>
              <name value="Boston Radiology Center"/>
              <telecom>
                <system value="phone"/>
                <value value="781-232-3200"/>
                <use value="work"/>
              </telecom>
              <address>
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
                  <valueCoding>
                    <system value="urn:iso:std:iso:3166:-2"/>
                    <code value="US-MA"/>
                  </valueCoding>
                </extension>
                <line value="32 Fruit Street"/>
                <city value="Boston"/>
                <state value="MA"/>
                <postalCode value="02114"/>
                <country value="US"/>
              </address>
            </Organization>
          </resource>
        </entry>
        <entry id="patient1001">
          <fullUrl value="http://example.org/fhir/Patient/patient1001"/>
          <resource>
            <Patient>
              <id value="patient1001"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
              </text>
              <identifier>
                <system value="http://example.com/identifiers/patient"/>
                <value value="1001"/>
              </identifier>
              <name>
                <text value="Eve Betterhalf"/>
                <family value="Betterhalf"/>
                <given value="Eve"/>
              </name>
              <telecom>
                <system value="phone"/>
                <value value="781-949-4949"/>
                <use value="mobile"/>
              </telecom>
              <gender value="female"/>
              <birthDate value="1955-07-23"/>
              <address>
                <text value="222 Burlington Road, Bedford MA 01730"/>
              </address>
              <maritalStatus>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
                  <code value="U"/>
                  <display value="unmarried"/>
                </coding>
              </maritalStatus>
              <communication>
                <language>
                  <coding>
                    <system value="urn:ietf:bcp:47"/>
                    <code value="en-US"/>
                    <display value="English (United States)"/>
                  </coding>
                </language>
                <preferred value="true"/>
              </communication>
            </Patient>
          </resource>
        </entry>
        <entry id="coverage1001">
          <fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
          <resource>
            <Coverage>
              <id value="coverage1001"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="coverage1001"></a><a name="hccoverage1001"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Coverage &quot;coverage1001&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --&gt; 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td>Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Copay Percentage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>
              </text>
              <extension
                         url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
                <valueCode value="insurance"/>
              </extension>
              <extension
                         url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
                <valueBoolean value="false"/>
              </extension>
              <status value="active"/>
              <subscriberId value="PFP123450000"/>
              <beneficiary>🔗 
                <reference value="Patient/patient1001"/>
              </beneficiary>
              <relationship>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
                  <code value="self"/>
                  <display value="Self"/>
                </coding>
              </relationship>
              <period>
                <start value="2021-01-01"/>
                <end value="2022-01-01"/>
              </period>
              <payor>🔗 
                <reference value="Organization/org1001"/>
              </payor>
              <class>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                    <code value="plan"/>
                    <display value="Plan"/>
                  </coding>
                </type>
                <value value="Premim Family Plus"/>
                <name value="Premim Family Plus Plan"/>
              </class>
              <costToBeneficiary>
                <type>
                  <coding>
                    <system
                            value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
                    <code value="copaypct"/>
                    <display value="Copay Percentage"/>
                  </coding>
                </type>
                <valueQuantity>
                  <value value="20"/>
                </valueQuantity>
              </costToBeneficiary>
            </Coverage>
          </resource>
        </entry>
        <entry id="org1001">
          <fullUrl value="http://example.org/fhir/Organization/org1001"/>
          <resource>
            <Organization>
              <id value="org1001"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1001"></a><a name="hcorg1001"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization &quot;org1001&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US</p></div>
              </text>
              <identifier>
                <type>
                  <coding>
                    <system
                            value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
                    <code value="ETIN"/>
                  </coding>
                </type>
                <value value="ETIN-3200002"/>
              </identifier>
              <active value="true"/>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/organization-type"/>
                  <code value="pay"/>
                  <display value="Payer"/>
                </coding>
              </type>
              <name value="Umbrella Insurance Company"/>
              <telecom>
                <system value="phone"/>
                <value value="860-547-5001"/>
                <use value="work"/>
              </telecom>
              <address>
                <extension
                           url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
                  <valueCoding>
                    <system value="urn:iso:std:iso:3166:-2"/>
                    <code value="US-CT"/>
                  </valueCoding>
                </extension>
                <line value="680 Asylum Street"/>
                <city value="Hartford"/>
                <state value="CT"/>
                <postalCode value="06155"/>
                <country value="US"/>
              </address>
            </Organization>
          </resource>
        </entry>
        <entry id="PCT-DeviceRequest-1">
          <fullUrl
                   value="http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1"/>
          <resource>
            <DeviceRequest>
              <id value="PCT-DeviceRequest-1"/>
              <meta>
                <profile
                         value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest"/>
              </meta>
              <text>
                <status value="additional"/>
                <div xmlns="http://www.w3.org/1999/xhtml"><p><a name="PCT-DeviceRequest-1"></a><a name="hcPCT-DeviceRequest-1"></a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource DeviceRequest &quot;PCT-DeviceRequest-1&quot;</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-devicerequest.html">PCT GFE DeviceRequest</a></p></div><p><b>status</b>: active</p><p><b>intent</b>: proposal</p><p><b>code</b>: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(HCPCSReleaseCodeSets#L1820)</span></p><p><b>subject</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> &quot; BETTERHALF&quot;</p></div>
              </text>
              <status value="active"/>
              <intent value="proposal"/>
              <codeCodeableConcept>
                <coding>
                  <system
                          value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
                  <code value="L1820"/>
                  <display
                           value="KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT"/>
                </coding>
              </codeCodeableConcept>
              <subject>🔗 
                <reference value="Patient/patient1001"/>
              </subject>
            </DeviceRequest>
          </resource>
        </entry>
      </Bundle>
    </resource>
  </entry>
</Bundle>