Generated Narrative: Composition PCT-AEOB-Composition-1 Profile: PCT AEOB Composition Request Initiation Time: 2025-01-08 09:01:00+0500 identifier: http://www.example.org/identifiers/composition/019283475 status: Final type: Advanced explanation of benefits category: Estimation Packet date: 2025-01-10 11:01:00+0500 author: Organization Umbrella Insurance Company Organization GFE Service Help INC. title: Advanced Explanation of Benefit Packet for Eve Betterhalf - 2025-01-10
Advanced Explanation of Benefit Packet for Eve Betterhalf - 2025-01-10
Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1 Profile: PCT Advanced EOB Summary Service Description: Example service In Network Provider Options Link: http://example.org/out-of-network.html status: Active type: Estimate Summary use: Predetermination patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001) billablePeriod: 2022-01-01 --> 2022-01-01 created: 2021-10-12 insurer: Organization Umbrella Insurance Company provider: ?rref? outcome: Processing Complete Insurances - Focal Coverage * true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01 total category: Submitted Amount Amounts - Value Currency * 200 United States dollar total category: Member liability Amounts - Value Currency * 20 United States dollar total category: Eligible Amount Amounts - Value Currency * 190 United States dollar ProcessNotes - Extension Text * processNote disclaimer text benefitPeriod: 2022-01-01 --> 2022-01-01 benefitBalance category: Medical Care unit: Individual term: Annual Financials - Extension Type Allowed[x] Used[x] * Allowed $1.00 (USD) $1.00 (USD)
Generated Narrative: PCT-GFE-Missing-Bundle-1 patient: Eve Betterhalf Female, DoB: 1955-07-23 (http://example.com/identifiers/patient#1001) coverage: Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01 organization: Umbrella Insurance Company Requested Services device request: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
Generated Narrative: ExplanationOfBenefit PCT-AEOB-1 Profile: PCT Advanced EOB GFE Reference: Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-23473847; type = collection; timestamp = 2021-11-09 11:01:00+0500 Service Description: Example service In Network Provider Options Link: http://example.org/out-of-network.html identifier: Unique Claim Identifier/?ngen-9? status: Active type: Institutional use: Predetermination patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001) created: 2021-10-12 insurer: Organization Umbrella Insurance Company provider: Organization Boston Radiology Center priority: Normal claim: Identifier: http://example.com/identifiers/bundle/59688475-2324-3242-23473847 outcome: Processing Complete Insurances - Focal Coverage * true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01 item sequence: 1 revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem 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: 2022-01-01 Nets - Value Currency * 200 United States dollar Adjudications - Extension Category * Medical Management Adjudications - Extension Category * Medical Management * Submitted Amount * Member Liability total category: Submitted Amount Amounts - Value Currency * 200 United States dollar total category: Member liability Amounts - Value Currency * 20 United States dollar total category: Eligible Amount Amounts - Value Currency * 190 United States dollar ProcessNotes - Extension Text * processNote disclaimer text benefitPeriod: 2022-01-01 --> 2023-01-01 benefitBalance category: Medical Care unit: Individual term: Annual Financials - Extension Type Allowed[x] Used[x] * Allowed $1.00 (USD) $1.00 (USD)
Magnetic Resonance Technology (MRT) - Brain/brain stem
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
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)
Generated Narrative: Coverage coverage1001 Profile: PCT Coverage Extension Definition for Coverage.kind for Version 5.0: insurance status: Active subscriberId: PFP123450000 beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001) relationship: Self period: 2021-01-01 --> 2022-01-01 payor: Organization Umbrella Insurance Company Classes - Type Value Name * Plan Premim Family Plus Premim Family Plus Plan CostToBeneficiaries - Type Value[x] * Copay Percentage 20
Generated Narrative: Organization org1001 Profile: PCT Organization identifier: Electronic Transmitter Identification Number/ETIN-3200002 active: true type: Payer name: Umbrella Insurance Company telecom: ph: 860-547-5001(Work) address: 680 Asylum Street Hartford CT 06155 US
Generated Narrative: Organization Submitter-Org-1 Profile: PCT Organization identifier: Electronic Transmitter Identification Number/ETIN-10010301 active: true type: Non-Healthcare Business or Corporation name: GFE Service Help INC. contact purpose: GFE-related name: Clara Sender telecom: ph: 781-632-3209(Work), csender@GFEServiceHelp.com
Generated Narrative: Organization org1002 Profile: PCT Organization identifier: United States National Provider Identifier/9941339100, Tax ID number/TAX-3211001 active: true type: Healthcare Provider name: Boston Radiology Center telecom: ph: 781-232-3200(Work) address: 32 Fruit Street Boston MA 02114 US
Unspecified focal traumatic brain injury
Diagnostic Neuroimaging (Radiology) Physician