Bundle PCT-GFE-Bundle-Inst-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-1

Resource Claim:

Resource Claim "PCT-GFE-Summary-1"

Profile: PCT Good Faith Estimate Summary

status: active

type: Estimate Summary (PCT Estimate Type Code System#estimate-summary)

use: predetermination

patient: Patient/patient1001 " BETTERHALF"

billablePeriod: 2021-10-31 --> 2021-10-31

created: 2021-10-05

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: ??

priority: Normal (Process Priority Codes#normal)

Diagnoses

-	Sequence	Diagnosis[x]	Type	PackageCode
*	1	Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30)	Principal Diagnosis (Example Diagnosis Type Codes#principal)	Head trauma - concussion (Example Diagnosis Related Group Codes#400)

Insurances

-	Sequence	Focal	Coverage
*	1	true	Coverage/coverage1001

Totals

-	Value	Currency
*	200	USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Institutional-1

Resource Claim:

Resource Claim "PCT-GFE-Institutional-1"

Profile: PCT Good Faith Estimate Institutional

ProviderEventMethodology: EEMM1021

GFEDisclaimer: For estimation purposes only

GFEServiceLinkingInfo

url

linkingIdentifier

value: 223452-2342-2435-008001

url

plannedPeriodOfService

value: 2021-10-31

identifier: Placer Identifier/GFEProviderAssignedID0001

status: active

type: Institutional (Claim Type Codes#institutional)

use: predetermination

patient: Patient/patient1001 " BETTERHALF"

created: 2021-10-05

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: Organization/Submitter-Org-1 "GFE Service Help INC."

priority: Normal (Process Priority Codes#normal)

Payees

-	Type
*	Provider (Payee Type Codes#provider)

referral: : Referral Number

SupportingInfos

-	Sequence	Category	Code
*	1	Type of Bill (PCT GFE Supporting Info Type Code System#typeofbill)	Hospital Inpatient (Part A) (AHA NUBC Type Of Bill Codes#011X)

Diagnoses

-	Sequence	Diagnosis[x]	Type	PackageCode
*	1	Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30)	Principal Diagnosis (Example Diagnosis Type Codes#principal)	Head trauma - concussion (Example Diagnosis Related Group Codes#400)

Insurances

-	Sequence	Focal	Coverage
*	1	true	Coverage/coverage1001

item

Service Description: Imaging

sequence: 1

revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)

productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)

modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)

serviced: 2021-10-31

quantity: 1

Nets

-	Value	Currency
*	200	USD

Totals

-	Value	Currency
*	200	USD

Entry 3 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1

Resource Organization:

Resource Organization "Submitter-Org-1"

Profile: PCT Organization

identifier: Electronic Transmitter Identification Number/ETIN-10010301

active: true

type: Non-Healthcare Business or Corporation (Organization type#bus)

name: GFE Service Help INC.

Contacts

-	Purpose	Name	Telecom
*	GFE-related (PCT Organization Contact Purpose Type Code System#GFERELATED)	Clara Sender	ph: 781-632-3209(WORK), csender@GFEServiceHelp.com

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

Resource Organization "org1001"

Profile: PCT Organization

identifier: Electronic Transmitter Identification Number/ETIN-3200002

active: true

type: Payer (Organization type#pay)

name: Umbrella Insurance Company

telecom: ph: 860-547-5001(WORK)

address: 680 Asylum Street Hartford CT 06155 US

Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

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)

Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

Resource Coverage "coverage1001"

Profile: PCT Coverage

Extension Definition for Coverage.kind for Version 5.0: insurance

status: active

subscriberId: PFP123450000

beneficiary: Patient/patient1001 " BETTERHALF"

relationship: Self (SubscriberPolicyholder Relationship Codes#self)

period: 2021-01-01 --> 2022-01-01

payor: Organization/org1001 "Umbrella Insurance Company"

Classes

-	Type	Value	Name
*	Plan (Coverage Class Codes#plan)	Premim Family Plus	Premim Family Plus Plan

CostToBeneficiaries

-	Type	Value[x]
*	Copay Percentage (Coverage Copay Type Codes#copaypct)	20