Patient Cost Transparency Implementation Guide
0.1.0 - STU 1 Ballot
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 
<Bundle xmlns="http://hl7.org/fhir">
<id value="PCT-AEOB-Bundle-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-1234567"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-10T11:01:00+05:00"/>
<entry id="PCT-AEOB-1">
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Inst-Example-1"/>
<resource>
<ExplanationOfBenefit>
<id value="PCT-AEOB-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><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">Resource "PCT-AEOB-1" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-aeob.html">PCT Advanced EOB</a></p></div><p><b>GFE Reference</b>: <a href="Bundle-PCT-GFE-Bundle-Inst-1.html">Bundle/PCT-GFE-Bundle-Inst-1</a></p><p><b>Disclaimer</b>: Estimate Only ...</p><p><b>Expiration Date</b>: 2021-10-31</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> " BETTERHALF"</p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization/org1001</a> "Umbrella Insurance Company"</p><p><b>provider</b>: <a href="Organization-org1002.html">Organization/org1002</a> "Boston Radiology Center"</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>EstimatedDateOfService</b>: 2021-10-31</p><p><b>sequence</b>: 1</p><p><b>revenue</b>: Revenue Code 1 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTGFEItemRevenueCS.html">PCT GFE Item Revenue Code System</a>#2011)</span></p><p><b>productOrService</b>: Some CPT Code 1 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTGFEItemProcedureCodes.html">PCT GFE Item Procedure Code System</a>#33502)</span></p><p><b>modifier</b>: Some CPT Code 2 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTGFEItemProcedureCodes.html">PCT GFE Item Procedure Code System</a>#34503)</span></p><blockquote><p><b>adjudication</b></p><p><b>Subject To Medical Management</b>: Concurrent Review (Details: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS code concurrent-review = 'Concurrent Review', stated as 'Concurrent Review')</p><p><b>category</b>: Paid to provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTAdjudicationCategoryType.html">PCT Adjudication Category Type</a>#paidtoprovider)</span></p></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/2.1.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference">
<valueReference>
<reference value="Bundle/PCT-GFE-Bundle-Inst-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/disclaimer">
<valueString value="Estimate Only ..."/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/expirationDate">
<valueDate value="2021-10-31"/>
</extension>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
<display value="Institutional"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference value="Patient/patient1001"/>
</patient>
<created value="2021-10-12"/>
<insurer>
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo">
<valueUrl value="http://example.com/out-of-network.html"/>
</extension>
<reference value="Organization/org1002"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<outcome value="complete"/>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService">
<valueDate value="2021-10-31"/>
</extension>
<sequence value="1"/>
<revenue>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemRevenueCS"/>
<code value="2011"/>
<display value="Revenue Code 1"/>
</coding>
</revenue>
<productOrService>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemProcedureCodes"/>
<code value="33502"/>
<display value="Some CPT Code 1"/>
</coding>
</productOrService>
<modifier>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemProcedureCodes"/>
<code value="34503"/>
<display value="Some CPT Code 2"/>
</coding>
</modifier>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
<valueCoding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"/>
<code value="concurrent-review"/>
<display value="Concurrent Review"/>
</valueCoding>
</extension>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryType"/>
<code value="paidtoprovider"/>
<display value="Paid to provider"/>
</coding>
</category>
<amount>
<value value="200"/>
<currency value="USD"/>
</amount>
</adjudication>
</item>
<total>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
</category>
<amount>
<value value="200"/>
<currency value="USD"/>
</amount>
</total>
</ExplanationOfBenefit>
</resource>
</entry>
</Bundle>
IG © 2021+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pct#0.1.0 based on FHIR 4.0.1. Generated 2021-12-04
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