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-GFE-Bundle-Inst-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-23473847"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-09T11:01:00+05:00"/>
<entry id="PCT-GFE-Inst-Example-1">
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Inst-Example-1"/>
<resource>
<Claim>
<id value="PCT-GFE-Institutional-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/pct-gfe-Institutional"/>
</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-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>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter">
<valueReference>
<reference value="Organization/Submitter-Org-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeProviderAssignedIdentifier">
<valueIdentifier>
<value value="GFEProviderAssignedID0001"/>
</valueIdentifier>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
<valueString value="EEMM1021"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/interTransIdentifier">
<valueIdentifier>
<value value="InterTransID0001"/>
</valueIdentifier>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
<extension url="linkingIdentifier">
<valueString value="223452-2342-2435-008001"/>
</extension>
<extension url="plannedPeriodOfService">
<valueDate value="2021-10-31"/>
</extension>
</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="predetermination"/>
<patient>
<reference value="Patient/patient1001"/>
</patient>
<created value="2021-10-05"/>
<insurer>
<reference value="Organization/org1001"/>
</insurer>
<provider>
<reference value="Organization/org1002"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
</payee>
<referral>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
<valueString value="REF12022002-121"/>
</extension>
<display value="Referral Number"/>
</referral>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<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>
<quantity>
<value value="1"/>
</quantity>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
<detail>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/compoundDrugLinkingNum">
<valueInteger value="123456"/>
</extension>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://hl7.org/fhir/sid/ndc"/>
<code value="47781-457"/>
</coding>
</productOrService>
</detail>
</item>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</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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