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Source1

{
  "resourceType": "Claim",
  "id": "PCT-GFE-Institutional-MRI",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
      "valueString": "EEMM1021"
    },
    {
      "extension": [
        {
          "url": "linkingIdentifier",
          "valueIdentifier": {
            "system": "http://example.org/Claim/identifiers",
            "value": "223452-2342-2435-008002"
          }
        },
        {
          "url": "plannedPeriodOfService",
          "valueDate": "2022-02-02"
        }
      ],
      "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"
          }
        ]
      },
      "value": "GFEProviderAssignedID0001MRI"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "institutional",
        "display": "Institutional"
      }
    ]
  },
  "use": "predetermination",
  "patient": {
    "reference": "Patient/patient1001"
  },
  "created": "2022-02-02",
  "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": "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": "REF12022002-122"
      }
    ],
    "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": "example-bill-type"
          }
        ]
      }
    }
  ],
  "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"
          }
        ]
      },
      "servicedDate": "2022-02-02",
      "quantity": {
        "value": 1
      },
      "net": {
        "value": 266,
        "currency": "USD"
      }
    }
  ],
  "total": {
    "value": 266,
    "currency": "USD"
  }
}