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 - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="PCT-AEOB-1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"/>
  </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-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>
  </text>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference">
    <valueReference>
      <reference value="Bundle/PCT-GFE-Bundle-Inst-1"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/disclaimer">
    <valueString value="Estimate Only ..."/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/expirationDate">
    <valueDate value="2021-10-31"/>
  </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="claim"/>
  <patient>
    <reference value="Patient/patient1001"/>
  </patient>
  <created value="2021-10-12"/>
  <insurer>
    <reference value="Organization/org1001"/>
  </insurer>
  <provider>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo">
      <valueUrl value="http://example.com/out-of-network.html"/>
    </extension>
    <reference value="Organization/org1002"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <outcome value="complete"/>
  <insurance>
    <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>
    <net>
      <value value="200"/>
      <currency value="USD"/>
    </net>
    <adjudication>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
        <valueCoding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"/>
          <code value="concurrent-review"/>
          <display value="Concurrent Review"/>
        </valueCoding>
      </extension>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryType"/>
          <code value="paidtoprovider"/>
          <display value="Paid to provider"/>
        </coding>
      </category>
      <amount>
        <value value="200"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
    </category>
    <amount>
      <value value="200"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>