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

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

Resource Claim:

Generated Narrative: Claim

Resource Claim "PCT-GFE-Summary-MRI"

Profile: PCT Good Faith Estimate Summary

status: ACTIVE

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

use: PREDETERMINATION

patient: See on this page: Patient/patient1001

billablePeriod: 2021-10-31 --> (ongoing)

created: 2021-10-05

insurer: See on this page: Organization/org1001

provider: ??

priority: Normal (Process Priority Codes#normal)

Diagnoses

-	Sequence	Diagnosis[x]	Type
*	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)

Insurances

-	Sequence	Focal	Coverage
*	1	true	See on this page: Coverage/coverage1001

Totals

-	Value	Currency
*	200	USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI

Resource Claim:

Generated Narrative: Claim

Resource Claim "PCT-GFE-Professional-MRI"

Profile: PCT Good Faith Estimate Professional

ProviderEventMethodology: EEMM1022

GFEServiceLinkingInfo

url

linkingIdentifier

value: 223452-2342-2435-008001

url

plannedPeriodOfService

value: 2021-10-31

identifier: Placer Identifier/GFEProviderAssignedID0002

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREDETERMINATION

patient: See on this page: Patient/patient1001

created: 2021-10-05

insurer: See on this page: Organization/org1001

provider: See on this page: Practitioner/Submitter-Practitioner-1

priority: Normal (Process Priority Codes#normal)

Payees

-	Type
*	Provider (Payee Type Codes#provider)

referral: : Referral Number

Diagnoses

-	Sequence	Diagnosis[x]	Type
*	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)

Insurances

-	Sequence	Focal	Coverage
*	1	true	See on this page: Coverage/coverage1001

item

Service Description: Imaging

GFEBillingProviderLineItemCtrlNum: GFEBillingProviderLineItemCtrlNum-0001

sequence: 1

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

location: Inpatient Hospital (CMS Place of Service Codes (POS)#21)

quantity: 1

UnitPrices

-	Value	Currency
*	200	USD

Nets

-	Value	Currency
*	200	USD

Totals

-	Value	Currency
*	200	USD

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

Resource Practitioner:

Generated Narrative: Practitioner

Resource Practitioner "Submitter-Practitioner-1"

Profile: PCT Practitioner

identifier: National provider identifier/6456789016, Electronic Transmitter Identification Number/ETIN-20020001

active: true

name: Nora Ologist

telecom: ph: 860-547-3301(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