{ "resourceType" : "Claim", "id" : "PCT-GFE-Institutional-1", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"] }, "text" : { "status" : "extensions", "div" : "

Generated Narrative: Claim PCT-GFE-Institutional-1

Profile: PCT Good Faith Estimate Institutional

ProviderEventMethodology: EEMM1021

GFEDisclaimer: For estimation purposes only

GFEServiceLinkingInfo

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

-SequenceCategoryCode
*1Type of BillHospital Inpatient (Part A)

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injuryPrincipal DiagnosisHead trauma - concussion

Insurances

-SequenceFocalCoverage
*1trueCoverage: 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

-ValueCurrency
*200United States dollar

Totals

-ValueCurrency
*200United States dollar
" }, "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology", "valueString" : "EEMM1021" }, { "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer", "valueString" : "For estimation purposes only" }, { "extension" : [{ "url" : "linkingIdentifier", "valueIdentifier" : { "system" : "http://example.org/Claim/identifiers", "value" : "223452-2342-2435-008001" } }, { "url" : "plannedPeriodOfService", "valueDate" : "2021-10-31" }], "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo" }], "identifier" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "PLAC", "display" : "Placer Identifier" }] }, "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "value" : "GFEProviderAssignedID0001" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "institutional", "display" : "Institutional" }] }, "use" : "predetermination", "patient" : { "reference" : "Patient/patient1001" }, "created" : "2021-10-05", "insurer" : { "reference" : "Organization/org1001" }, "provider" : { "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy", "valueCodeableConcept" : { "coding" : [{ "system" : "http://nucc.org/provider-taxonomy", "code" : "2085D0003X", "display" : "Diagnostic Neuroimaging (Radiology) Physician" }] } }, { "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling", "valueBoolean" : true }], "reference" : "Organization/Submitter-Org-1" }, "priority" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/processpriority", "code" : "normal" }] }, "payee" : { "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/payeetype", "code" : "provider" }] } }, "referral" : { "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber", "valueString" : "REF12022002-121" }], "display" : "Referral Number" }, "supportingInfo" : [{ "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "typeofbill" }] }, "code" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/TypeOfBill", "code" : "011X", "display" : "Hospital Inpatient (Part A)" }] } }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "S06.30", "display" : "Unspecified focal traumatic brain injury" }] }, "type" : [{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "principal" }] }], "packageCode" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup", "code" : "400", "display" : "Head trauma - concussion" }] } }], "insurance" : [{ "sequence" : 1, "focal" : true, "coverage" : { "reference" : "Coverage/coverage1001" } }], "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription", "valueString" : "Imaging" }], "sequence" : 1, "revenue" : { "coding" : [{ "system" : "https://www.nubc.org/CodeSystem/RevenueCodes", "code" : "0611", "display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "70551", "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" }] }, "modifier" : [{ "coding" : [{ "system" : "http://www.ama-assn.org/go/cpt", "code" : "70551", "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" }] }], "servicedDate" : "2021-10-31", "quantity" : { "value" : 1 }, "net" : { "value" : 200, "currency" : "USD" } }], "total" : { "value" : 200, "currency" : "USD" } }