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
Institutional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10
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)
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
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
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 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 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
Unspecified focal traumatic brain injury
Diagnostic Neuroimaging (Radiology) Physician
Magnetic Resonance Technology (MRT) - Brain/brain stem
Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT