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 
{
"resourceType" : "ExplanationOfBenefit",
"id" : "PCT-AEOB-1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
]
},
"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-AEOB-1\" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob.html\">PCT Advanced EOB</a></p></div><p><b>GFE Reference</b>: <a href=\"Bundle-PCT-GFE-Bundle-Inst-1.html\">Bundle/PCT-GFE-Bundle-Inst-1</a></p><p><b>Disclaimer</b>: Estimate Only ...</p><p><b>Expiration Date</b>: 2021-10-31</p><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>: claim</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Patient/patient1001</a> \" BETTERHALF\"</p><p><b>created</b>: 2021-10-12</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><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</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><blockquote><p><b>adjudication</b></p><p><b>Subject To Medical Management</b>: Concurrent Review (Details: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS code concurrent-review = 'Concurrent Review', stated as 'Concurrent Review')</p><p><b>category</b>: Paid to provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTAdjudicationCategoryType.html\">PCT Adjudication Category Type</a>#paidtoprovider)</span></p></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/2.1.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p></blockquote></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
"valueReference" : {
"reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/disclaimer",
"valueString" : "Estimate Only ..."
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/expirationDate",
"valueDate" : "2021-10-31"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional",
"display" : "Institutional"
}
]
},
"use" : "claim",
"patient" : {
"reference" : "Patient/patient1001"
},
"created" : "2021-10-12",
"insurer" : {
"reference" : "Organization/org1001"
},
"provider" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo",
"valueUrl" : "http://example.com/out-of-network.html"
}
],
"reference" : "Organization/org1002"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"outcome" : "complete",
"insurance" : [
{
"focal" : true,
"coverage" : {
"reference" : "Coverage/coverage1001"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService",
"valueDate" : "2021-10-31"
}
],
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemRevenueCS",
"code" : "2011",
"display" : "Revenue Code 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"
}
]
}
],
"net" : {
"value" : 200,
"currency" : "USD"
},
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryType",
"code" : "paidtoprovider",
"display" : "Paid to provider"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
}
]
}
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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