{ "resourceType" : "Bundle", "id" : "PCT-GFE-Bundle-Inst-1", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"] }, "identifier" : { "system" : "http://example.com/identifiers/bundle", "value" : "59688475-2324-3242-23473847" }, "type" : "collection", "timestamp" : "2021-11-09T11:01:00+05:00", "entry" : [{ "fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Summary-1", "resource" : { "resourceType" : "Claim", "id" : "PCT-GFE-Summary-1", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Claim PCT-GFE-Summary-1

Profile: PCT Good Faith Estimate Summary

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 --> 2021-10-31

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: ?rref?

priority: Normal

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injuryPrincipal DiagnosisHead trauma - concussion

Insurances

-SequenceFocalCoverage
*1trueCoverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

Totals

-ValueCurrency
*200United States dollar
" }, "status" : "active", "type" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse", "code" : "estimate-summary", "display" : "Estimate Summary" }] }, "use" : "predetermination", "patient" : { "reference" : "Patient/patient1001" }, "billablePeriod" : { "start" : "2021-10-31", "end" : "2021-10-31" }, "created" : "2021-10-05", "insurer" : { "reference" : "Organization/org1001" }, "provider" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode" : "not-applicable" }] }, "priority" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/processpriority", "code" : "normal" }] }, "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "S06.30", "display" : "Unspecified focal traumatic brain injury" }] }, "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "principal" }] }], "packageCode" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup", "code" : "400", "display" : "Head trauma - concussion" }] } }], "insurance" : [{ "sequence" : 1, "focal" : true, "coverage" : { "reference" : "Coverage/coverage1001" } }], "total" : { "value" : 200, "currency" : "USD" } } }, { "fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Institutional-1", "resource" : { "resourceType" : "Claim", "id" : "PCT-GFE-Institutional-1", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"] }, "text" : { "status" : "extensions", "div" : "

Generated Narrative: Claim PCT-GFE-Institutional-1

Profile: PCT Good Faith Estimate Institutional

ProviderEventMethodology: EEMM1021

GFEDisclaimer: For estimation purposes only

GFEServiceLinkingInfo

identifier: Placer Identifier/GFEProviderAssignedID0001

status: Active

type: Institutional

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: Organization GFE Service Help INC.

priority: Normal

Payees

-Type
*Provider

referral: Referral Number

SupportingInfos

-SequenceCategoryCode
*1Type of BillHospital Inpatient (Part A)

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injuryPrincipal DiagnosisHead trauma - concussion

Insurances

-SequenceFocalCoverage
*1trueCoverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

item

Service Description: Imaging

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: 2021-10-31

quantity: 1

Nets

-ValueCurrency
*200United States dollar

Totals

-ValueCurrency
*200United States dollar
" }, "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology", "valueString" : "EEMM1021" }, { "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer", "valueString" : "For estimation purposes only" }, { "extension" : [{ "url" : "linkingIdentifier", "valueIdentifier" : { "system" : "http://example.org/Claim/identifiers", "value" : "223452-2342-2435-008001" } }, { "url" : "plannedPeriodOfService", "valueDate" : "2021-10-31" }], "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo" }], "identifier" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "PLAC", "display" : "Placer Identifier" }] }, "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "value" : "GFEProviderAssignedID0001" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "institutional", "display" : "Institutional" }] }, "use" : "predetermination", "patient" : { "reference" : "Patient/patient1001" }, "created" : "2021-10-05", "insurer" : { "reference" : "Organization/org1001" }, "provider" : { "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy", "valueCodeableConcept" : { "coding" : [{ "system" : "http://nucc.org/provider-taxonomy", "code" : "2085D0003X", "display" : "Diagnostic Neuroimaging (Radiology) Physician" }] } }, { "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling", "valueBoolean" : true }], "reference" : "Organization/Submitter-Org-1" }, "priority" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/processpriority", "code" : "normal" }] }, "payee" : { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/payeetype", "code" : "provider" }] } }, "referral" : { "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber", "valueString" : "REF12022002-121" }], "display" : "Referral Number" }, "supportingInfo" : [{ "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "typeofbill" }] }, "code" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/TypeOfBill", "code" : "011X", "display" : "Hospital Inpatient (Part A)" }] } }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "S06.30", "display" : "Unspecified focal traumatic brain injury" }] }, "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "principal" }] }], "packageCode" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup", "code" : "400", "display" : "Head trauma - concussion" }] } }], "insurance" : [{ "sequence" : 1, "focal" : true, "coverage" : { "reference" : "Coverage/coverage1001" } }], "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription", "valueString" : "Imaging" }], "sequence" : 1, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0611", "display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "70551", "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" }] }, "modifier" : [{ "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "70551", "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" }] }], "servicedDate" : "2021-10-31", "quantity" : { "value" : 1 }, "net" : { "value" : 200, "currency" : "USD" } }], "total" : { "value" : 200, "currency" : "USD" } } }, { "fullUrl" : "http://example.org/fhir/Organization/Submitter-Org-1", "resource" : { "resourceType" : "Organization", "id" : "Submitter-Org-1", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"] }, "text" : { "status" : "generated", "div" : "

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

" }, "identifier" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "ETIN" }] }, "value" : "ETIN-10010301" }], "active" : true, "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/organization-type", "code" : "bus" }] }], "name" : "GFE Service Help INC.", "contact" : [{ "purpose" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType", "code" : "GFERELATED" }] }, "name" : { "text" : "Clara Sender" }, "telecom" : [{ "system" : "phone", "value" : "781-632-3209", "use" : "work" }, { "system" : "email", "value" : "csender@GFEServiceHelp.com", "use" : "work" }] }] } }, { "fullUrl" : "http://example.org/fhir/Organization/org1001", "resource" : { "resourceType" : "Organization", "id" : "org1001", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"] }, "text" : { "status" : "generated", "div" : "

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

" }, "identifier" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "ETIN" }] }, "value" : "ETIN-3200002" }], "active" : true, "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/organization-type", "code" : "pay", "display" : "Payer" }] }], "name" : "Umbrella Insurance Company", "telecom" : [{ "system" : "phone", "value" : "860-547-5001", "use" : "work" }], "address" : [{ "line" : ["680 Asylum Street"], "city" : "Hartford", "state" : "CT", "postalCode" : "06155", "country" : "US" }] } }, { "fullUrl" : "http://example.org/fhir/Patient/patient1001", "resource" : { "resourceType" : "Patient", "id" : "patient1001", "meta" : { "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"] }, "text" : { "status" : "additional", "div" : "

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)
" }, "identifier" : [{ "system" : "http://example.com/identifiers/patient", "value" : "1001" }], "name" : [{ "text" : "Eve Betterhalf", "family" : "Betterhalf", "given" : ["Eve"] }], "telecom" : [{ "system" : "phone", "value" : "781-949-4949", "use" : "mobile" }], "gender" : "female", "birthDate" : "1955-07-23", "address" : [{ "text" : "222 Burlington Road, Bedford MA 01730" }], "maritalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus", "code" : "U", "display" : "unmarried" }] }, "communication" : [{ "language" : { "coding" : [{ "system" : "urn:ietf:bcp:47", "code" : "en-US", "display" : "English (United States)" }] }, "preferred" : true }] } }, { "fullUrl" : "http://example.org/fhir/Coverage/coverage1001", "resource" : { "resourceType" : "Coverage", "id" : "coverage1001", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"] }, "text" : { "status" : "extensions", "div" : "

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

-TypeValueName
*PlanPremim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage20
" }, "extension" : [{ "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind", "valueCode" : "insurance" }], "status" : "active", "subscriberId" : "PFP123450000", "beneficiary" : { "reference" : "Patient/patient1001" }, "relationship" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship", "code" : "self", "display" : "Self" }] }, "period" : { "start" : "2021-01-01", "end" : "2022-01-01" }, "payor" : [{ "reference" : "Organization/org1001" }], "class" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/coverage-class", "code" : "plan", "display" : "Plan" }] }, "value" : "Premim Family Plus", "name" : "Premim Family Plus Plan" }], "costToBeneficiary" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code" : "copaypct", "display" : "Copay Percentage" }] }, "valueQuantity" : { "value" : 20 } }] } }] }