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 Claim: PCT-GFE-Institutional-1

Generated Narrative

Resource "PCT-GFE-Institutional-1"

Profile: PCT Good Faith Estimate Institutional

GFESubmitter: Organization/Submitter-Org-1 "GFE Service Help INC."

GFEProviderAssignedIdentifier: id: GFEProviderAssignedID0001

ProviderEventMethodology: EEMM1021

InterTransIdentifier: id: InterTransID0001

GFEServiceLinkingInfo

value: 223452-2342-2435-008001

value: 2021-10-31

status: active

type: Institutional (Claim Type Codes#institutional)

use: predetermination

patient: Patient/patient1001 " BETTERHALF"

created: 2021-10-05

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: Organization/org1002 "Boston Radiology Center"

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

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)

quantity: 1

Details

-ExtensionSequenceProductOrService
*1nitroglycerin (product) (National drug codes#47781-457)