FHIR IG analytics| Package | hl7.fhir.us.davinci-pct |
| Resource Type | Bundle |
| Id | Bundle-PCT-GFE-Packet-Prof-1.json |
| FHIR Version | R4 |
No resources found
No resources found
No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Bundle",
"id": "PCT-GFE-Packet-Prof-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-packet"
]
},
"identifier": {
"system": "http://example.com/identifiers/bundle",
"value": "59688475-2324-3242-2347384711"
},
"type": "document",
"timestamp": "2024-03-29T11:01:00+05:00",
"entry": [
{
"id": "PCT-GFE-Composition-Prof-1",
"fullUrl": "http://example.org/fhir/Composition/PCT-GFE-Composition-Prof-1",
"resource": {
"resourceType": "Composition",
"id": "PCT-GFE-Composition-Prof-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-composition"
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_PCT-GFE-Composition-Prof-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Composition PCT-GFE-Composition-Prof-1</b></p><a name=\"PCT-GFE-Composition-Prof-1\"> </a><a name=\"hcPCT-GFE-Composition-Prof-1\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-composition.html\">PCT GFE Composition</a></p></div><p><b>Request Initiation Time</b>: 2025-01-08 09:01:00+0500</p><p><b>RequestOriginationType</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFERequestTypeCSTemporaryTrialUse scheduled-request}\">Scheduled Service Request</span></p><blockquote><p><b>GFEServiceLinkingInfo</b></p><ul><li>linkingIdentifier: <code>http://example.org/Claim/identifiers</code>/223452-2342-2435-008003</li><li>plannedPeriodOfService: 2021-10-31</li></ul></blockquote><p><b>identifier</b>: <code>http://www.example.org/identifiers/composition</code>/019283477</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 111480-0}\">Good faith estimate</span></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse estimate}\">Estimation Packet</span></p><p><b>date</b>: 2025-01-10 11:01:00+0500</p><p><b>author</b>: </p><ul><li><a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></li><li><a href=\"Practitioner-Submitter-Practitioner-1.html\">Practitioner Nora Ologist</a></li></ul><p><b>title</b>: Professional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10</p></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestInitiationTime",
"valueInstant": "2025-01-08T09:01:00+05:00"
},
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestOriginationType",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFERequestTypeCSTemporaryTrialUse",
"code": "scheduled-request"
}
]
}
},
{
"extension": [
{
"url": "linkingIdentifier",
"valueIdentifier": {
"system": "http://example.org/Claim/identifiers",
"value": "223452-2342-2435-008003"
}
},
{
"url": "plannedPeriodOfService",
"valueDate": "2021-10-31"
}
],
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
}
],
"identifier": {
"system": "http://www.example.org/identifiers/composition",
"value": "019283477"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "111480-0",
"display": "Good faith estimate"
}
]
},
"category": [
{
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse",
"code": "estimate"
}
]
}
],
"subject": {
"reference": "Patient/patient1001"
},
"date": "2025-01-10T11:01:00+05:00",
"author": [
{
"reference": "Organization/org1001"
},
{
"reference": "Practitioner/Submitter-Practitioner-1"
}
],
"title": "Professional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10",
"section": [
{
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code": "coverage-section"
}
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Coverage coverage1001</b></p><a name=\"coverage1001\"/><a name=\"hccoverage1001\"/><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-coverage.html\">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: Active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><h3>Classes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\">Plan</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type copaypct}\">Copay Percentage</span></td><td>20</td></tr></table></div>"
},
"entry": [
{
"reference": "Coverage/coverage1001"
}
]
},
{
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code": "gfe-section"
}
]
},
"author": [
{
"reference": "Practitioner/Submitter-Practitioner-1"
}
],
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PCT-GFE-Summary-MRI</b></p><a name=\"PCT-GFE-Summary-MRI\"/><a name=\"hcPCT-GFE-Summary-MRI\"/><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-summary.html\">PCT Good Faith Estimate Summary</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>billablePeriod</b>: 2021-10-31 --> (ongoing)</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: ?rref?</p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.30}\">Unspecified focal traumatic brain injury</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/diagnosistype principal}\">Principal Diagnosis</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup 400}\">Head trauma - concussion</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01</a></td></tr></table><h3>Totals</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>200</td><td>United States dollar</td></tr></table></div>"
},
"entry": [
{
"reference": "Bundle/PCT-GFE-Bundle-Prof-1"
}
]
},
{
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code": "gfe-section"
}
]
},
"author": [
{
"reference": "Organization/org1001"
}
],
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: PCT-GFE-Missing-Bundle-1</b></p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 (http://example.com/identifiers/patient#1001)</a></p><p><b>coverage</b>: <a href=\"Patient-patient1001.html\">Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01</a></p><p><b>organization</b>: <a href=\"Organization-org1001.html\">Umbrella Insurance Company</a></p><h3>Requested Services</h3><ul><li><b>device request</b>: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT</li></ul></div>"
},
"entry": [
{
"reference": "Bundle/PCT-GFE-Missing-Bundle-1"
}
]
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Patient/patient1001",
"resource": {
"resourceType": "Patient",
"id": "patient1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_patient1001\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}\">unmarried</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Languages spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes: {urn:ietf:bcp:47 en-US}\">English (United States)</span> (preferred)</td></tr></table></div>"
},
"identifier": [
{
"system": "http://example.com/identifiers/patient",
"value": "1001"
}
],
"name": [
{
"text": "Eve Betterhalf",
"family": "Betterhalf",
"given": [
"Eve"
]
}
],
"telecom": [
{
"system": "phone",
"value": "781-949-4949",
"use": "mobile"
}
],
"gender": "female",
"birthDate": "1955-07-23",
"address": [
{
"text": "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U",
"display": "unmarried"
}
]
},
"communication": [
{
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-US",
"display": "English (United States)"
}
]
},
"preferred": true
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Coverage/coverage1001",
"resource": {
"resourceType": "Coverage",
"id": "coverage1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_coverage1001\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage coverage1001</b></p><a name=\"coverage1001\"> </a><a name=\"hccoverage1001\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-coverage.html\">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: Active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><h3>Classes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\">Plan</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type copaypct}\">Copay Percentage</span></td><td>20</td></tr></table></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind",
"valueCode": "insurance"
}
],
"status": "active",
"subscriberId": "PFP123450000",
"beneficiary": {
"reference": "Patient/patient1001"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "Self"
}
]
},
"period": {
"start": "2021-01-01",
"end": "2022-01-01"
},
"payor": [
{
"reference": "Organization/org1001"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan",
"display": "Plan"
}
]
},
"value": "Premim Family Plus",
"name": "Premim Family Plus Plan"
}
],
"costToBeneficiary": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code": "copaypct",
"display": "Copay Percentage"
}
]
},
"valueQuantity": {
"value": 20
}
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Practitioner/Submitter-Practitioner-1",
"resource": {
"resourceType": "Practitioner",
"id": "Submitter-Practitioner-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_Submitter-Practitioner-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner Submitter-Practitioner-1</b></p><a name=\"Submitter-Practitioner-1\"> </a><a name=\"hcSubmitter-Practitioner-1\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-practitioner.html\">PCT Practitioner</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/7.0.1/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/9941339100, Electronic Transmitter Identification Number/ETIN-20020001</p><p><b>active</b>: true</p><p><b>name</b>: Nora Ologist</p><p><b>telecom</b>: ph: 860-547-3301(Work), <a href=\"mailto:csender@GFEServiceHelp.com\">csender@GFEServiceHelp.com</a></p></div>"
},
"identifier": [
{
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "9941339100"
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ETIN"
}
]
},
"system": "http://example.com/us-etin",
"value": "ETIN-20020001"
}
],
"active": true,
"name": [
{
"text": "Nora Ologist",
"family": "Ologist",
"given": [
"Nora"
]
}
],
"telecom": [
{
"system": "phone",
"value": "860-547-3301",
"use": "work"
},
{
"system": "email",
"value": "csender@GFEServiceHelp.com",
"use": "work"
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Organization/org1001",
"resource": {
"resourceType": "Organization",
"id": "org1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_org1001\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization org1001</b></p><a name=\"org1001\"> </a><a name=\"hcorg1001\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-organization.html\">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type pay}\">Payer</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(Work)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US </p></div>"
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ETIN"
}
]
},
"value": "ETIN-3200002"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "pay",
"display": "Payer"
}
]
}
],
"name": "Umbrella Insurance Company",
"telecom": [
{
"system": "phone",
"value": "860-547-5001",
"use": "work"
}
],
"address": [
{
"line": [
"680 Asylum Street"
],
"city": "Hartford",
"state": "CT",
"postalCode": "06155",
"country": "US"
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Bundle/PCT-GFE-Bundle-Prof-1",
"resource": {
"resourceType": "Bundle",
"id": "PCT-GFE-Bundle-Prof-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"
]
},
"identifier": {
"system": "http://example.com/identifiers/bundle",
"value": "59688475-2324-3242-23473847"
},
"type": "collection",
"timestamp": "2021-11-09T11:01:00+05:00",
"entry": [
{
"fullUrl": "http://example.org/fhir/Claim/PCT-GFE-Summary-MRI",
"resource": {
"resourceType": "Claim",
"id": "PCT-GFE-Summary-MRI",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"
]
},
"status": "active",
"type": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
"code": "estimate-summary",
"display": "Estimate Summary"
}
]
},
"use": "predetermination",
"patient": {
"reference": "Patient/patient1001"
},
"billablePeriod": {
"start": "2021-10-31"
},
"created": "2021-10-05",
"insurer": {
"reference": "Organization/org1001"
},
"provider": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode": "not-applicable"
}
]
},
"priority": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
"code": "normal"
}
]
},
"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"
}
}
],
"total": {
"value": 200,
"currency": "USD"
}
}
},
{
"fullUrl": "http://example.org/fhir/Claim/PCT-GFE-Professional-MRI",
"resource": {
"resourceType": "Claim",
"id": "PCT-GFE-Professional-MRI",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"
]
},
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
"valueString": "EEMM1022"
},
{
"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": "GFEProviderAssignedID0002"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional",
"display": "Professional"
}
]
},
"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"
}
]
}
}
],
"reference": "Practitioner/Submitter-Practitioner-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": "REF12022002-122"
}
],
"display": "Referral Number"
},
"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"
},
{
"url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum",
"valueIdentifier": {
"value": "GFEBillingProviderLineItemCtrlNum-0001"
}
}
],
"sequence": 1,
"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",
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "21",
"display": "Inpatient Hospital"
}
]
},
"quantity": {
"value": 1
},
"unitPrice": {
"value": 200,
"currency": "USD"
},
"net": {
"value": 200,
"currency": "USD"
}
}
],
"total": {
"value": 200,
"currency": "USD"
}
}
},
{
"fullUrl": "http://example.org/fhir/Practitioner/Submitter-Practitioner-1",
"resource": {
"resourceType": "Practitioner",
"id": "Submitter-Practitioner-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"
]
},
"identifier": [
{
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "9941339100"
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ETIN"
}
]
},
"system": "http://example.com/us-etin",
"value": "ETIN-20020001"
}
],
"active": true,
"name": [
{
"text": "Nora Ologist",
"family": "Ologist",
"given": [
"Nora"
]
}
],
"telecom": [
{
"system": "phone",
"value": "860-547-3301",
"use": "work"
},
{
"system": "email",
"value": "csender@GFEServiceHelp.com",
"use": "work"
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Organization/org1001",
"resource": {
"resourceType": "Organization",
"id": "org1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ETIN"
}
]
},
"value": "ETIN-3200002"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "pay",
"display": "Payer"
}
]
}
],
"name": "Umbrella Insurance Company",
"telecom": [
{
"system": "phone",
"value": "860-547-5001",
"use": "work"
}
],
"address": [
{
"line": [
"680 Asylum Street"
],
"city": "Hartford",
"state": "CT",
"postalCode": "06155",
"country": "US"
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Patient/patient1001",
"resource": {
"resourceType": "Patient",
"id": "patient1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}\">unmarried</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Languages spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes: {urn:ietf:bcp:47 en-US}\">English (United States)</span> (preferred)</td></tr></table></div>"
},
"identifier": [
{
"system": "http://example.com/identifiers/patient",
"value": "1001"
}
],
"name": [
{
"text": "Eve Betterhalf",
"family": "Betterhalf",
"given": [
"Eve"
]
}
],
"telecom": [
{
"system": "phone",
"value": "781-949-4949",
"use": "mobile"
}
],
"gender": "female",
"birthDate": "1955-07-23",
"address": [
{
"text": "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U",
"display": "unmarried"
}
]
},
"communication": [
{
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-US",
"display": "English (United States)"
}
]
},
"preferred": true
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Coverage/coverage1001",
"resource": {
"resourceType": "Coverage",
"id": "coverage1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"extension": [
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind",
"valueCode": "insurance"
}
],
"status": "active",
"subscriberId": "PFP123450000",
"beneficiary": {
"reference": "Patient/patient1001"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "Self"
}
]
},
"period": {
"start": "2021-01-01",
"end": "2022-01-01"
},
"payor": [
{
"reference": "Organization/org1001"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan",
"display": "Plan"
}
]
},
"value": "Premim Family Plus",
"name": "Premim Family Plus Plan"
}
],
"costToBeneficiary": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code": "copaypct",
"display": "Copay Percentage"
}
]
},
"valueQuantity": {
"value": 20
}
}
]
}
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1",
"resource": {
"resourceType": "Bundle",
"id": "PCT-GFE-Missing-Bundle-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle"
]
},
"identifier": {
"system": "http://example.com/identifiers/bundle",
"value": "59688475-2324-3242-2347384376"
},
"type": "collection",
"timestamp": "2024-03-27T11:01:00+05:00",
"entry": [
{
"fullUrl": "http://example.org/fhir/Organization/org1002",
"resource": {
"resourceType": "Organization",
"id": "org1002",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier": [
{
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "9941339100"
},
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "TAX"
}
]
},
"system": "urn:oid:2.16.840.1.113883.4.4",
"value": "TAX-3211001"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "prov",
"display": "Healthcare Provider"
}
]
}
],
"name": "Boston Radiology Center",
"telecom": [
{
"system": "phone",
"value": "781-232-3200",
"use": "work"
}
],
"address": [
{
"line": [
"32 Fruit Street"
],
"city": "Boston",
"state": "MA",
"postalCode": "02114",
"country": "US"
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Patient/patient1001",
"resource": {
"resourceType": "Patient",
"id": "patient1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"
]
},
"text": {
"status": "additional",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}\">unmarried</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Languages spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes: {urn:ietf:bcp:47 en-US}\">English (United States)</span> (preferred)</td></tr></table></div>"
},
"identifier": [
{
"system": "http://example.com/identifiers/patient",
"value": "1001"
}
],
"name": [
{
"text": "Eve Betterhalf",
"family": "Betterhalf",
"given": [
"Eve"
]
}
],
"telecom": [
{
"system": "phone",
"value": "781-949-4949",
"use": "mobile"
}
],
"gender": "female",
"birthDate": "1955-07-23",
"address": [
{
"text": "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "U",
"display": "unmarried"
}
]
},
"communication": [
{
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-US",
"display": "English (United States)"
}
]
},
"preferred": true
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Coverage/coverage1001",
"resource": {
"resourceType": "Coverage",
"id": "coverage1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"extension": [
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind",
"valueCode": "insurance"
}
],
"status": "active",
"subscriberId": "PFP123450000",
"beneficiary": {
"reference": "Patient/patient1001"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self",
"display": "Self"
}
]
},
"period": {
"start": "2021-01-01",
"end": "2022-01-01"
},
"payor": [
{
"reference": "Organization/org1001"
}
],
"class": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-class",
"code": "plan",
"display": "Plan"
}
]
},
"value": "Premim Family Plus",
"name": "Premim Family Plus Plan"
}
],
"costToBeneficiary": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code": "copaypct",
"display": "Copay Percentage"
}
]
},
"valueQuantity": {
"value": 20
}
}
]
}
},
{
"fullUrl": "http://example.org/fhir/Organization/org1001",
"resource": {
"resourceType": "Organization",
"id": "org1001",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ETIN"
}
]
},
"value": "ETIN-3200002"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "pay",
"display": "Payer"
}
]
}
],
"name": "Umbrella Insurance Company",
"telecom": [
{
"system": "phone",
"value": "860-547-5001",
"use": "work"
}
],
"address": [
{
"line": [
"680 Asylum Street"
],
"city": "Hartford",
"state": "CT",
"postalCode": "06155",
"country": "US"
}
]
}
},
{
"id": "PCT-DeviceRequest-1",
"fullUrl": "http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1",
"resource": {
"resourceType": "DeviceRequest",
"id": "PCT-DeviceRequest-1",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest"
]
},
"status": "active",
"intent": "proposal",
"codeCodeableConcept": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "L1820",
"display": "KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT"
}
]
},
"subject": {
"reference": "Patient/patient1001"
}
}
}
]
}
}
]
}