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-AEOB-1 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ExplanationOfBenefit;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "PCT-AEOB-1"];
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob>     ]
  ];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ];
     fhir:Narrative.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>"
  ];
  fhir:DomainResource.extension [
     fhir:index 0;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference" ];
     fhir:Extension.valueReference [
       fhir:Reference.reference [ fhir:value "Bundle/PCT-GFE-Bundle-Inst-1" ]     ]
  ], [
     fhir:index 1;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/disclaimer" ];
     fhir:Extension.valueString [ fhir:value "Estimate Only ..." ]
  ], [
     fhir:index 2;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/expirationDate" ];
     fhir:Extension.valueDate [ fhir:value "2021-10-31"^^xsd:date ]
  ];
  fhir:ExplanationOfBenefit.status [ fhir:value "active"];
  fhir:ExplanationOfBenefit.type [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ];
       fhir:Coding.code [ fhir:value "institutional" ];
       fhir:Coding.display [ fhir:value "Institutional" ]     ]
  ];
  fhir:ExplanationOfBenefit.use [ fhir:value "claim"];
  fhir:ExplanationOfBenefit.patient [
     fhir:Reference.reference [ fhir:value "Patient/patient1001" ]
  ];
  fhir:ExplanationOfBenefit.created [ fhir:value "2021-10-12"^^xsd:date];
  fhir:ExplanationOfBenefit.insurer [
     fhir:Reference.reference [ fhir:value "Organization/org1001" ]
  ];
  fhir:ExplanationOfBenefit.provider [
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo" ];
       fhir:Extension.valueUrl [ fhir:value "http://example.com/out-of-network.html" ]     ];
     fhir:Reference.reference [ fhir:value "Organization/org1002" ]
  ];
  fhir:ExplanationOfBenefit.priority [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/processpriority" ];
       fhir:Coding.code [ fhir:value "normal" ]     ]
  ];
  fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"];
  fhir:ExplanationOfBenefit.insurance [
     fhir:index 0;
     fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ];
     fhir:ExplanationOfBenefit.insurance.coverage [
       fhir:Reference.reference [ fhir:value "Coverage/coverage1001" ]     ]
  ];
  fhir:ExplanationOfBenefit.item [
     fhir:index 0;
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService" ];
       fhir:Extension.valueDate [ fhir:value "2021-10-31"^^xsd:date ]     ];
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ];
     fhir:ExplanationOfBenefit.item.revenue [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemRevenueCS" ];
         fhir:Coding.code [ fhir:value "2011" ];
         fhir:Coding.display [ fhir:value "Revenue Code 1" ]       ]     ];
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemProcedureCodes" ];
         fhir:Coding.code [ fhir:value "33502" ];
         fhir:Coding.display [ fhir:value "Some CPT Code 1" ]       ]     ];
     fhir:ExplanationOfBenefit.item.modifier [
       fhir:index 0;
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFEItemProcedureCodes" ];
         fhir:Coding.code [ fhir:value "34503" ];
         fhir:Coding.display [ fhir:value "Some CPT Code 2" ]       ]     ];
     fhir:ExplanationOfBenefit.item.net [
       fhir:Money.value [ fhir:value "200"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ];
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0;
       fhir:Element.extension [
         fhir:index 0;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt" ];
         fhir:Extension.valueCoding [
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS" ];
           fhir:Coding.code [ fhir:value "concurrent-review" ];
           fhir:Coding.display [ fhir:value "Concurrent Review" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryType" ];
           fhir:Coding.code [ fhir:value "paidtoprovider" ];
           fhir:Coding.display [ fhir:value "Paid to provider" ]         ]       ];
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "200"^^xsd:decimal ];
         fhir:Money.currency [ fhir:value "USD" ]       ]     ]
  ];
  fhir:ExplanationOfBenefit.total [
     fhir:index 0;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
         fhir:Coding.code [ fhir:value "submitted" ];
         fhir:Coding.display [ fhir:value "Submitted Amount" ]       ]     ];
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "200"^^xsd:decimal ];
       fhir:Money.currency [ fhir:value "USD" ]     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.