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 
{
"resourceType" : "Bundle",
"id" : "PCT-GFE-Bundle-Inst-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" : [
{
"id" : "PCT-GFE-Inst-Example-1",
"fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Inst-Example-1",
"resource" : {
"resourceType" : "Claim",
"id" : "PCT-GFE-Institutional-1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/pct-gfe-Institutional"
]
},
"text" : {
"status" : "extensions",
"div" : "<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-GFE-Institutional-1\" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-pct-gfe-Institutional.html\">PCT Good Faith Estimate Institutional</a></p></div><p><b>GFESubmitter</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization/Submitter-Org-1</a> \"GFE Service Help INC.\"</p><p><b>GFEProviderAssignedIdentifier</b>: id: GFEProviderAssignedID0001</p><p><b>ProviderEventMethodology</b>: EEMM1021</p><p><b>InterTransIdentifier</b>: id: InterTransID0001</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><p><b>value</b>: 223452-2342-2435-008001</p><p><b>value</b>: 2021-10-31</p></blockquote><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>: predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Patient/patient1001</a> \" BETTERHALF\"</p><p><b>created</b>: 2021-10-05</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><h3>Payees</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td></tr><tr><td>*</td><td>Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/2.1.0/CodeSystem-payeetype.html\">ClaimPayeeTypeCodes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</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>*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/2.1.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/2.1.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/2.1.0/CodeSystem-ex-diagnosisrelatedgroup.html\">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</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><p><b>quantity</b>: 1</p><h3>Details</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>ProductOrService</b></td></tr><tr><td>*</td><td></td><td>1</td><td>nitroglycerin (product) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/2.1.0/CodeSystem-v3-ndc.html\">National drug codes</a>#47781-457)</span></td></tr></table></blockquote></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter",
"valueReference" : {
"reference" : "Organization/Submitter-Org-1"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeProviderAssignedIdentifier",
"valueIdentifier" : {
"value" : "GFEProviderAssignedID0001"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
"valueString" : "EEMM1021"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/interTransIdentifier",
"valueIdentifier" : {
"value" : "InterTransID0001"
}
},
{
"extension" : [
{
"url" : "linkingIdentifier",
"valueString" : "223452-2342-2435-008001"
},
{
"url" : "plannedPeriodOfService",
"valueDate" : "2021-10-31"
}
],
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
}
],
"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" : {
"reference" : "Organization/org1002"
},
"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"
},
"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/ex-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/estimatedDateOfService",
"valueDate" : "2021-10-31"
}
],
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemRevenueCS",
"code" : "2011",
"display" : "Revenue Code 1"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemProcedureCodes",
"code" : "33502",
"display" : "Some CPT Code 1"
}
]
},
"modifier" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemProcedureCodes",
"code" : "34503",
"display" : "Some CPT Code 2"
}
]
}
],
"quantity" : {
"value" : 1
},
"net" : {
"value" : 200,
"currency" : "USD"
},
"detail" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/compoundDrugLinkingNum",
"valueInteger" : 123456
}
],
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/ndc",
"code" : "47781-457"
}
]
}
}
]
}
],
"total" : {
"value" : 200,
"currency" : "USD"
}
}
}
]
}
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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