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-GFE-Bundle-Prof-1

Bundle PCT-GFE-Bundle-Prof-1 of type collection

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

Resource Claim:

Generated Narrative

Resource "PCT-GFE-Professional-1"

Profile: PCT Good Faith Estimate Professional

GFESubmitter: Practitioner/Submitter-Practitioner-1 " OLOGIST"

GFEProviderAssignedIdentifier: id: GFEProviderAssignedID0002

ProviderEventMethodology: EEMM1022

InterTransIdentifier: id: InterTransID0002

GFEServiceLinkingInfo

value: 223452-2342-2435-008001

value: 2021-10-31

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREDETERMINATION

patient: Patient/patient1001 " BETTERHALF"

created: 2021-10-05

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: PractitionerRole/pracRole002

priority: Normal (Process Priority Codes#normal)

Payees

-Type
*Provider (ClaimPayeeTypeCodes#provider)

referral: : Referral Number

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30)Principal Diagnosis (Example Diagnosis Type Codes#principal)Head trauma - concussion (Example Diagnosis Related Group Codes#400)

Insurances

-SequenceFocalCoverage
*1trueCoverage/coverage1001

item

EstimatedDateOfService: 2021-10-31

GFEBillingProviderLineItemCtrlNum: id: GFEBillingProviderLineItemCtrlNum-0001

sequence: 1

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

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

location: Inpatient Hospital (2.16.840.1.113883.15.5#21)

quantity: 1