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

: PCT-GFE-Institutional-1 - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <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>