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

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

Resource Claim:

Generated Narrative: Claim

Resource Claim "PCT-GFE-Institutional-1"

Profile: PCT Good Faith Estimate Institutional

Texts

-	Div
*	<div/>

GFESubmitter: See above (Organization/Submitter-Org-1)

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: See above (Patient/patient1001)

created: 2021-10-05

insurer: See above (Organization/org1001)

provider: See above (Organization/Submitter-Org-1)

priority: Normal (Process Priority Codes#normal)

Payees

-	Type
*	Provider (Claim 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
*	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 above (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) (Current Procedural Terminology (CPT®)#70551)

modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem) (Current Procedural Terminology (CPT®)#70551)

serviced: 2021-10-31

quantity: 1

Nets

-	Value	Currency
*	200	USD

Totals

-	Value	Currency
*	200	USD

Entry 2 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1

Resource Organization:

Generated Narrative: Organization

Resource Organization "Submitter-Org-1"

Profile: PCT Organization

Texts

-	Div
*	<div/>

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

Resource Organization:

Generated Narrative: Organization

Resource Organization "org1001"

Profile: PCT Organization

Texts

-	Div
*	<div/>

identifier: Electronic Transmitter Identification Number: ETIN-3200002

active: true

type: Payer (Organization type#pay)

name: Umbrella Insurance Company

Contacts

-	Telecom	Address
*	ph: 860-547-5001(WORK)	680 Asylum Street Hartford CT 06155 US

Entry 4 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

Eve Betterhalf Female, DoB: 1955-07-23 ( id: 1001)

Entry 5 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

Generated Narrative: Coverage

Resource Coverage "coverage1001"

Profile: PCT Coverage

Texts

-	Div
*	<div/>

status: ACTIVE

subscriberId: id: PFP123450000

beneficiary: See above (Patient/patient1001)

relationship: Self (SubscriberPolicyholder Relationship Codes#self)

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

Classes

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

CostToBeneficiaries

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