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-Professional-1 - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "PCT-GFE-Professional-1",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"
    ]
  },
  "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-Professional-1\" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-professional.html\">PCT Good Faith Estimate Professional</a></p></div><p><b>GFESubmitter</b>: <a href=\"Practitioner-Submitter-Practitioner-1.html\">Practitioner/Submitter-Practitioner-1</a> \" OLOGIST\"</p><p><b>GFEProviderAssignedIdentifier</b>: id: GFEProviderAssignedID0002</p><p><b>ProviderEventMethodology</b>: EEMM1022</p><p><b>InterTransIdentifier</b>: id: InterTransID0002</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>: Professional <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>#professional)</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=\"PractitionerRole-pracRole002.html\">PractitionerRole/pracRole002</a></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>GFEBillingProviderLineItemCtrlNum</b>: id: GFEBillingProviderLineItemCtrlNum-0001</p><p><b>sequence</b>: 1</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>location</b>: Inpatient Hospital <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (2.16.840.1.113883.15.5#21)</span></p><p><b>quantity</b>: 1</p></blockquote></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter",
      "valueReference" : {
        "reference" : "Practitioner/Submitter-Practitioner-1"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeProviderAssignedIdentifier",
      "valueIdentifier" : {
        "value" : "GFEProviderAssignedID0002"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
      "valueString" : "EEMM1022"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/interTransIdentifier",
      "valueIdentifier" : {
        "value" : "InterTransID0002"
      }
    },
    {
      "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" : "professional",
        "display" : "Professional"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "Patient/patient1001"
  },
  "created" : "2021-10-05",
  "insurer" : {
    "reference" : "Organization/org1001"
  },
  "provider" : {
    "reference" : "PractitionerRole/pracRole002"
  },
  "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" : "REF12022002-122"
      }
    ],
    "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"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum",
          "valueIdentifier" : {
            "value" : "GFEBillingProviderLineItemCtrlNum-0001"
          }
        }
      ],
      "sequence" : 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"
            }
          ]
        }
      ],
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://oidref.com/2.16.840.1.113883.15.5",
            "code" : "21",
            "display" : "Inpatient Hospital"
          }
        ]
      },
      "quantity" : {
        "value" : 1
      },
      "net" : {
        "value" : 200,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 200,
    "currency" : "USD"
  }
}