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
KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT