PCT-GFE-Packet-Inst-1
type: Bundle
node role: treeRoot
id:
  v: PCT-GFE-Packet-Inst-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-packet
    l: davinci-pct-gfe-packet
identifier:
  system:
    v: http://example.com/identifiers/bundle
    l: bundle
  value:
    v: 59688475-2324-3242-2347384711
type:
  v: document
timestamp:
  v: 2024-03-29T11:01:00+05:00
entry:
  id:
    v: PCT-GFE-Composition-Inst-1
  full url:
    v: http://example.org/fhir/Composition/PCT-GFE-Composition-Inst-1
    l: PCT-GFE-Composition-Inst-1
  resource: PCT-GFE-Composition-Inst-1
entry:
  full url:
    v: http://example.org/fhir/Patient/patient1001
    l: patient1001
  resource: patient1001
entry:
  full url:
    v: http://example.org/fhir/Coverage/coverage1001
    l: coverage1001
  resource: coverage1001
entry:
  full url:
    v: http://example.org/fhir/Organization/Submitter-Org-1
    l: Submitter-Org-1
  resource: Submitter-Org-1
entry:
  full url:
    v: http://example.org/fhir/Organization/org1001
    l: org1001
  resource: org1001
entry:
  full url:
    v: http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1
    l: PCT-GFE-Bundle-Inst-1
  resource: PCT-GFE-Bundle-Inst-1
entry:
  full url:
    v: http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1
    l: PCT-GFE-Missing-Bundle-1
  resource: PCT-GFE-Missing-Bundle-1

PCT-GFE-Composition-Inst-1
type: Composition
id:
  v: PCT-GFE-Composition-Inst-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-composition
    l: davinci-pct-gfe-composition
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Composition PCT-GFE-Composition-Inst-1 Profile: PCT GFE Composition Request Initiation Time: 2025-01-08 09:01:00+0500 RequestOriginationType: Nonscheduled Service Request GFEServiceLinkingInfo linkingIdentifier: http://example.org/Claim/identifiers/223452-2342-2435-008002 identifier: http://www.example.org/identifiers/composition/019283476 status: Final type: Good faith estimate category: Estimation Packet date: 2025-01-10 11:01:00+0500 author: Organization Umbrella Insurance Company Organization GFE Service Help INC. title: Institutional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10
extension:
  url:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestInitiationTime
    l: requestInitiationTime
  value: Instant
    v: 2025-01-08T09:01:00+05:00
extension:
  url:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestOriginationType
    l: requestOriginationType
  value: CodeableConcept
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFERequestTypeCSTemporaryTrialUse
        l: PCTGFERequestTypeCSTemporaryTrialUse
      code:
        v: nonscheduled-request
extension:
  extension:
    url:
      v: linkingIdentifier
      l: linkingIdentifier
    value: Identifier
      system:
        v: http://example.org/Claim/identifiers
        l: identifiers
      value:
        v: 223452-2342-2435-008002
  url:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo
    l: gfeServiceLinkingInfo
identifier:
  system:
    v: http://www.example.org/identifiers/composition
    l: composition
  value:
    v: 019283476
status:
  v: final
type:
  coding: https://loinc.org/rdf/111480-0
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: 111480-0
    display:
      v: Good faith estimate
category:
  coding:
    system:
      v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse
      l: PCTDocumentTypeTemporaryTrialUse
    code:
      v: estimate
subject:
  l: patient1001
  reference:
    v: Patient/patient1001
date:
  v: 2025-01-10T11:01:00+05:00
author:
  l: org1001
  reference:
    v: Organization/org1001
author:
  l: Submitter-Org-1
  reference:
    v: Organization/Submitter-Org-1
title:
  v: Institutional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10
section:
  code:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection
        l: PCTDocumentSection
      code:
        v: coverage-section
  text:
    status:
      v: extensions
    div:
      v: Generated Narrative: Coverage selfpaycoverage2001 Profile: PCT Coverage Extension Definition for Coverage.kind for Version 5.0: self-pay Self-Pay Declared: true status: Active subscriberId: Absent because : not-applicable beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001) relationship: Self payor: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
  entry:
    l: coverage1001
    reference:
      v: Coverage/coverage1001
section:
  code:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection
        l: PCTDocumentSection
      code:
        v: gfe-section
  author:
    l: Submitter-Org-1
    reference:
      v: Organization/Submitter-Org-1
  text:
    status:
      v: extensions
    div:
      v: Generated Narrative: Claim PCT-GFE-Institutional-1 Profile: PCT Good Faith Estimate Institutional ProviderEventMethodology: EEMM1021 GFEDisclaimer: For estimation purposes only GFEServiceLinkingInfo linkingIdentifier: http://example.org/Claim/identifiers/223452-2342-2435-008001 plannedPeriodOfService: 2021-10-31 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 - Sequence Category Code * 1 Type of Bill Hospital Inpatient (Part A) Diagnoses - Sequence Diagnosis[x] Type PackageCode * 1 Unspecified focal traumatic brain injury Principal Diagnosis Head trauma - concussion Insurances - Sequence Focal Coverage * 1 true Coverage: 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 - Value Currency * 200 United States dollar Totals - Value Currency * 200 United States dollar
  entry:
    l: PCT-GFE-Bundle-Inst-1
    reference:
      v: Bundle/PCT-GFE-Bundle-Inst-1
section:
  code:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection
        l: PCTDocumentSection
      code:
        v: gfe-section
  author:
    l: org1001
    reference:
      v: Organization/org1001
  text:
    status:
      v: extensions
    div:
      v: 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
  entry:
    l: PCT-GFE-Missing-Bundle-1
    reference:
      v: Bundle/PCT-GFE-Missing-Bundle-1

patient1001
type: Patient
id:
  v: patient1001
id:
  v: patient1001
id:
  v: patient1001
meta:
  profile:
    v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0
    l: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
meta:
  profile:
    v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0
    l: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
meta:
  profile:
    v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0
    l: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
text:
  status:
    v: additional
  div:
    v: 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)
text:
  status:
    v: additional
  div:
    v: 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)
text:
  status:
    v: additional
  div:
    v: 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:
    v: http://example.com/identifiers/patient
    l: patient
  value:
    v: 1001
identifier:
  system:
    v: http://example.com/identifiers/patient
    l: patient
  value:
    v: 1001
identifier:
  system:
    v: http://example.com/identifiers/patient
    l: patient
  value:
    v: 1001
name:
  text:
    v: Eve Betterhalf
  family:
    v: Betterhalf
  given:
    v: Eve
name:
  text:
    v: Eve Betterhalf
  family:
    v: Betterhalf
  given:
    v: Eve
name:
  text:
    v: Eve Betterhalf
  family:
    v: Betterhalf
  given:
    v: Eve
telecom:
  system:
    v: phone
  value:
    v: 781-949-4949
  use:
    v: mobile
telecom:
  system:
    v: phone
  value:
    v: 781-949-4949
  use:
    v: mobile
telecom:
  system:
    v: phone
  value:
    v: 781-949-4949
  use:
    v: mobile
gender:
  v: female
gender:
  v: female
gender:
  v: female
birth date:
  v: 1955-07-23
birth date:
  v: 1955-07-23
birth date:
  v: 1955-07-23
address:
  text:
    v: 222 Burlington Road, Bedford MA 01730
address:
  text:
    v: 222 Burlington Road, Bedford MA 01730
address:
  text:
    v: 222 Burlington Road, Bedford MA 01730
marital status:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-MaritalStatus
      l: v3-MaritalStatus
    code:
      v: U
    display:
      v: unmarried
marital status:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-MaritalStatus
      l: v3-MaritalStatus
    code:
      v: U
    display:
      v: unmarried
marital status:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-MaritalStatus
      l: v3-MaritalStatus
    code:
      v: U
    display:
      v: unmarried
communication:
  language:
    coding:
      system:
        v: urn:ietf:bcp:47
        l: 47
      code:
        v: en-US
      display:
        v: English (United States)
  preferred:
    v: true
communication:
  language:
    coding:
      system:
        v: urn:ietf:bcp:47
        l: 47
      code:
        v: en-US
      display:
        v: English (United States)
  preferred:
    v: true
communication:
  language:
    coding:
      system:
        v: urn:ietf:bcp:47
        l: 47
      code:
        v: en-US
      display:
        v: English (United States)
  preferred:
    v: true

coverage1001
type: Coverage
id:
  v: coverage1001
id:
  v: coverage1001
id:
  v: coverage1001
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage
    l: davinci-pct-coverage
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage
    l: davinci-pct-coverage
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage
    l: davinci-pct-coverage
text:
  status:
    v: extensions
  div:
    v: 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
extension:
  url:
    v: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    l: extension-Coverage.kind
  value: Code
    v: insurance
extension:
  url:
    v: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    l: extension-Coverage.kind
  value: Code
    v: insurance
extension:
  url:
    v: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    l: extension-Coverage.kind
  value: Code
    v: insurance
status:
  v: active
status:
  v: active
status:
  v: active
subscriber id:
  v: PFP123450000
subscriber id:
  v: PFP123450000
subscriber id:
  v: PFP123450000
beneficiary:
  l: patient1001
  reference:
    v: Patient/patient1001
beneficiary:
  l: patient1001
  reference:
    v: Patient/patient1001
beneficiary:
  l: patient1001
  reference:
    v: Patient/patient1001
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/subscriber-relationship
      l: subscriber-relationship
    code:
      v: self
    display:
      v: Self
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/subscriber-relationship
      l: subscriber-relationship
    code:
      v: self
    display:
      v: Self
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/subscriber-relationship
      l: subscriber-relationship
    code:
      v: self
    display:
      v: Self
period:
  start:
    v: 2021-01-01
  end:
    v: 2022-01-01
period:
  start:
    v: 2021-01-01
  end:
    v: 2022-01-01
period:
  start:
    v: 2021-01-01
  end:
    v: 2022-01-01
payor:
  l: org1001
  reference:
    v: Organization/org1001
payor:
  l: org1001
  reference:
    v: Organization/org1001
payor:
  l: org1001
  reference:
    v: Organization/org1001
class:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/coverage-class
        l: coverage-class
      code:
        v: plan
      display:
        v: Plan
  value:
    v: Premim Family Plus
  name:
    v: Premim Family Plus Plan
class:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/coverage-class
        l: coverage-class
      code:
        v: plan
      display:
        v: Plan
  value:
    v: Premim Family Plus
  name:
    v: Premim Family Plus Plan
class:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/coverage-class
        l: coverage-class
      code:
        v: plan
      display:
        v: Plan
  value:
    v: Premim Family Plus
  name:
    v: Premim Family Plus Plan
cost to beneficiary:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/coverage-copay-type
        l: coverage-copay-type
      code:
        v: copaypct
      display:
        v: Copay Percentage
  value: Quantity
    value:
      v: 20
cost to beneficiary:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/coverage-copay-type
        l: coverage-copay-type
      code:
        v: copaypct
      display:
        v: Copay Percentage
  value: Quantity
    value:
      v: 20
cost to beneficiary:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/coverage-copay-type
        l: coverage-copay-type
      code:
        v: copaypct
      display:
        v: Copay Percentage
  value: Quantity
    value:
      v: 20

Submitter-Org-1
type: Organization
id:
  v: Submitter-Org-1
id:
  v: Submitter-Org-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization
    l: davinci-pct-organization
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization
    l: davinci-pct-organization
text:
  status:
    v: generated
  div:
    v: 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:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: ETIN
  value:
    v: ETIN-10010301
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: ETIN
  value:
    v: ETIN-10010301
active:
  v: true
active:
  v: true
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
      l: organization-type
    code:
      v: bus
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
      l: organization-type
    code:
      v: bus
name:
  v: GFE Service Help INC.
name:
  v: GFE Service Help INC.
contact:
  purpose:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType
        l: PCTOrgContactPurposeType
      code:
        v: GFERELATED
  name:
    text:
      v: Clara Sender
  telecom:
    system:
      v: phone
    value:
      v: 781-632-3209
    use:
      v: work
  telecom:
    system:
      v: email
    use:
      v: work
contact:
  purpose:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType
        l: PCTOrgContactPurposeType
      code:
        v: GFERELATED
  name:
    text:
      v: Clara Sender
  telecom:
    system:
      v: phone
    value:
      v: 781-632-3209
    use:
      v: work
  telecom:
    system:
      v: email
    use:
      v: work

org1001
type: Organization
id:
  v: org1001
id:
  v: org1001
id:
  v: org1001
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization
    l: davinci-pct-organization
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization
    l: davinci-pct-organization
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization
    l: davinci-pct-organization
text:
  status:
    v: generated
  div:
    v: 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:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: ETIN
  value:
    v: ETIN-3200002
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: ETIN
  value:
    v: ETIN-3200002
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: ETIN
  value:
    v: ETIN-3200002
active:
  v: true
active:
  v: true
active:
  v: true
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
      l: organization-type
    code:
      v: pay
    display:
      v: Payer
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
      l: organization-type
    code:
      v: pay
    display:
      v: Payer
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
      l: organization-type
    code:
      v: pay
    display:
      v: Payer
name:
  v: Umbrella Insurance Company
name:
  v: Umbrella Insurance Company
name:
  v: Umbrella Insurance Company
telecom:
  system:
    v: phone
  value:
    v: 860-547-5001
  use:
    v: work
telecom:
  system:
    v: phone
  value:
    v: 860-547-5001
  use:
    v: work
telecom:
  system:
    v: phone
  value:
    v: 860-547-5001
  use:
    v: work
address:
  line:
    v: 680 Asylum Street
  city:
    v: Hartford
  state:
    v: CT
  postal code:
    v: 06155
  country:
    v: US
address:
  line:
    v: 680 Asylum Street
  city:
    v: Hartford
  state:
    v: CT
  postal code:
    v: 06155
  country:
    v: US
address:
  line:
    v: 680 Asylum Street
  city:
    v: Hartford
  state:
    v: CT
  postal code:
    v: 06155
  country:
    v: US

PCT-GFE-Bundle-Inst-1
type: Bundle
id:
  v: PCT-GFE-Bundle-Inst-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle
    l: davinci-pct-gfe-bundle
identifier:
  system:
    v: http://example.com/identifiers/bundle
    l: bundle
  value:
    v: 59688475-2324-3242-23473847
type:
  v: collection
timestamp:
  v: 2021-11-09T11:01:00+05:00
entry:
  full url:
    v: http://example.org/fhir/Claim/PCT-GFE-Summary-1
    l: PCT-GFE-Summary-1
  resource: PCT-GFE-Summary-1
entry:
  full url:
    v: http://example.org/fhir/Claim/PCT-GFE-Institutional-1
    l: PCT-GFE-Institutional-1
  resource: PCT-GFE-Institutional-1
entry:
  full url:
    v: http://example.org/fhir/Organization/Submitter-Org-1
    l: Submitter-Org-1
  resource: Submitter-Org-1
entry:
  full url:
    v: http://example.org/fhir/Organization/org1001
    l: org1001
  resource: org1001
entry:
  full url:
    v: http://example.org/fhir/Patient/patient1001
    l: patient1001
  resource: patient1001
entry:
  full url:
    v: http://example.org/fhir/Coverage/coverage1001
    l: coverage1001
  resource: coverage1001

PCT-GFE-Summary-1
type: Claim
id:
  v: PCT-GFE-Summary-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary
    l: davinci-pct-gfe-summary
status:
  v: active
type:
  coding:
    system:
      v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
      l: PCTEstimateTypeSummaryCSTemporaryTrialUse
    code:
      v: estimate-summary
    display:
      v: Estimate Summary
use:
  v: predetermination
patient:
  l: patient1001
  reference:
    v: Patient/patient1001
billable period:
  start:
    v: 2021-10-31
  end:
    v: 2021-10-31
created:
  v: 2021-10-05
insurer:
  l: org1001
  reference:
    v: Organization/org1001
provider:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/data-absent-reason
      l: data-absent-reason
    value: Code
      v: not-applicable
priority:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/processpriority
      l: processpriority
    code:
      v: normal
diagnosis:
  sequence:
    v: 1
  diagnosis: CodeableConcept
    coding:
      system:
        v: http://hl7.org/fhir/sid/icd-10-cm
        l: icd-10-cm
      code:
        v: S06.30
      display:
        v: Unspecified focal traumatic brain injury
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/diagnosistype
        l: diagnosistype
      code:
        v: principal
  package code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup
        l: ex-diagnosisrelatedgroup
      code:
        v: 400
      display:
        v: Head trauma - concussion
insurance:
  sequence:
    v: 1
  focal:
    v: true
  coverage:
    l: coverage1001
    reference:
      v: Coverage/coverage1001
total:
  value:
    v: 200
  currency:
    v: USD

PCT-GFE-Institutional-1
type: Claim
id:
  v: PCT-GFE-Institutional-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional
    l: davinci-pct-gfe-institutional
extension:
  url:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
    l: providerEventMethodology
  value: String
    v: EEMM1021
extension:
  url:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer
    l: gfeDisclaimer
  value: String
    v: For estimation purposes only
extension:
  extension:
    url:
      v: linkingIdentifier
      l: linkingIdentifier
    value: Identifier
      system:
        v: http://example.org/Claim/identifiers
        l: identifiers
      value:
        v: 223452-2342-2435-008001
  extension:
    url:
      v: plannedPeriodOfService
      l: plannedPeriodOfService
    value: Date
      v: 2021-10-31
  url:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo
    l: gfeServiceLinkingInfo
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: PLAC
      display:
        v: Placer Identifier
  system:
    v: http://terminology.hl7.org/CodeSystem/v2-0203
    l: v2-0203
  value:
    v: GFEProviderAssignedID0001
status:
  v: active
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/claim-type
      l: claim-type
    code:
      v: institutional
    display:
      v: Institutional
use:
  v: predetermination
patient:
  l: patient1001
  reference:
    v: Patient/patient1001
created:
  v: 2021-10-05
insurer:
  l: org1001
  reference:
    v: Organization/org1001
provider:
  l: Submitter-Org-1
  extension:
    url:
      v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy
      l: providerTaxonomy
    value: CodeableConcept
  extension:
    url:
      v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling
      l: gfeConsentForBalanceBilling
    value: Boolean
      v: true
  reference:
    v: Organization/Submitter-Org-1
priority:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/processpriority
      l: processpriority
    code:
      v: normal
payee:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/payeetype
        l: payeetype
      code:
        v: provider
referral:
  extension:
    url:
      v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber
      l: referralNumber
    value: String
      v: REF12022002-121
  display:
    v: Referral Number
supporting info:
  sequence:
    v: 1
  category:
    coding:
      system:
        v: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
        l: PCTSupportingInfoType
      code:
        v: typeofbill
  code:
    coding:
      system:
        v: https://www.nubc.org/CodeSystem/TypeOfBill
        l: TypeOfBill
      code:
        v: 011X
      display:
        v: Hospital Inpatient (Part A)
diagnosis:
  sequence:
    v: 1
  diagnosis: CodeableConcept
    coding:
      system:
        v: http://hl7.org/fhir/sid/icd-10-cm
        l: icd-10-cm
      code:
        v: S06.30
      display:
        v: Unspecified focal traumatic brain injury
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/diagnosistype
        l: diagnosistype
      code:
        v: principal
  package code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup
        l: ex-diagnosisrelatedgroup
      code:
        v: 400
      display:
        v: Head trauma - concussion
insurance:
  sequence:
    v: 1
  focal:
    v: true
  coverage:
    l: coverage1001
    reference:
      v: Coverage/coverage1001
item:
  extension:
    url:
      v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
      l: serviceDescription
    value: String
      v: Imaging
  sequence:
    v: 1
  revenue:
    coding:
      system:
        v: https://www.nubc.org/CodeSystem/RevenueCodes
        l: RevenueCodes
      code:
        v: 0611
      display:
        v: Magnetic Resonance Technology (MRT) - Brain/brain stem
  product or service:
    coding:
      system:
        v: http://www.ama-assn.org/go/cpt
        l: cpt
      code:
        v: 70551
      display:
        v: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
  modifier:
    coding:
      system:
        v: http://www.ama-assn.org/go/cpt
        l: cpt
  serviced: Date

PCT-GFE-Missing-Bundle-1
type: Bundle
id:
  v: PCT-GFE-Missing-Bundle-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle
    l: davinci-pct-gfe-missing-bundle
identifier:
  system:
    v: http://example.com/identifiers/bundle
    l: bundle
  value:
    v: 59688475-2324-3242-2347384376
type:
  v: collection
timestamp:
  v: 2024-03-27T11:01:00+05:00
entry:
  full url:
    v: http://example.org/fhir/Organization/org1002
    l: org1002
  resource: org1002
entry:
  full url:
    v: http://example.org/fhir/Patient/patient1001
    l: patient1001
  resource: patient1001
entry:
  full url:
    v: http://example.org/fhir/Coverage/coverage1001
    l: coverage1001
  resource: coverage1001
entry:
  full url:
    v: http://example.org/fhir/Organization/org1001
    l: org1001
  resource: org1001
entry:
  id:
    v: PCT-DeviceRequest-1
  full url:
    v: http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1
    l: PCT-DeviceRequest-1
  resource: PCT-DeviceRequest-1

org1002
type: Organization
id:
  v: org1002
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization
    l: davinci-pct-organization
identifier:
  system:
    v: http://hl7.org/fhir/sid/us-npi
    l: us-npi
  value:
    v: 9941339100
identifier:
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
        l: v2-0203
      code:
        v: TAX
  system:
    v: urn:oid:2.16.840.1.113883.4.4
    l: 2.16.840.1.113883.4.4
  value:
    v: TAX-3211001
active:
  v: true
type:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/organization-type
      l: organization-type
    code:
      v: prov
    display:
      v: Healthcare Provider
name:
  v: Boston Radiology Center
telecom:
  system:
    v: phone
  value:
    v: 781-232-3200
  use:
    v: work
address:
  line:
    v: 32 Fruit Street
  city:
    v: Boston
  state:
    v: MA
  postal code:
    v: 02114
  country:
    v: US

PCT-DeviceRequest-1
type: DeviceRequest
id:
  v: PCT-DeviceRequest-1
meta:
  profile:
    v: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest
    l: davinci-pct-devicerequest
status:
  v: active
intent:
  v: proposal
code: CodeableConcept
  coding:
    system:
      v: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
      l: HCPCSReleaseCodeSets
    code:
      v: L1820
    display:
      v: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
subject:
  l: patient1001
  reference:
    v: Patient/patient1001

v: 2085D0003X

v: Diagnostic Neuroimaging (Radiology) Physician

v: 70551

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

Date
v: 2021-10-31

value:
  v: 1

value:
  v: 200
currency:
  v: USD

value:
  v: 200
currency:
  v: USD