Patient Cost Transparency Implementation Guide
0.1.0 - STU 1 Ballot

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v0.1.0: STU 1 Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Example Bundle: PCT-AEOB-Bundle-1

Bundle PCT-AEOB-Bundle-1 of type collection

Entry 1 - Full URL = http://example.org/fhir/Claim/PCT-GFE-Inst-Example-1

Resource ExplanationOfBenefit:

Generated Narrative

Resource "PCT-AEOB-1"

Profile: PCT Advanced EOB

GFE Reference: Bundle/PCT-GFE-Bundle-Inst-1

Disclaimer: Estimate Only ...

Expiration Date: 2021-10-31

status: ACTIVE

type: Institutional (Claim Type Codes#institutional)

use: CLAIM

patient: Patient/patient1001 " BETTERHALF"

created: 2021-10-12

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: Organization/org1002 "Boston Radiology Center"

priority: Normal (Process Priority Codes#normal)

outcome: COMPLETE

Insurances

-FocalCoverage
*trueCoverage/coverage1001

item

EstimatedDateOfService: 2021-10-31

sequence: 1

revenue: Revenue Code 1 (PCT GFE Item Revenue Code System#2011)

productOrService: Some CPT Code 1 (PCT GFE Item Procedure Code System#33502)

modifier: Some CPT Code 2 (PCT GFE Item Procedure Code System#34503)

adjudication

Subject To Medical Management: Concurrent Review (Details: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS code concurrent-review = 'Concurrent Review', stated as 'Concurrent Review')

category: Paid to provider (PCT Adjudication Category Type#paidtoprovider)

total

category: Submitted Amount (Adjudication Value Codes#submitted)