Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
US
Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
US
This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions
Bundle PCT-AEOB-Bundle-1 of type collection
Entry 1 - fullUrl = http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1
Resource ExplanationOfBenefit:
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PCT-AEOB-Summary-1"
Profile: PCT Advanced EOB Summary
Service Description: Example service
In Network Provider Options Link: http://example.com/out-of-network.html
status: ACTIVE
type: Estimate Summary (PCT Estimate Type Code System#estimate-summary)
use: PREDETERMINATION
patient: See on this page: Patient/patient1001
billablePeriod: 2022-01-01 --> 2022-01-01
created: 2021-10-12
insurer: See on this page: Organization/org1001
provider: ??
outcome: COMPLETE
Insurances
Focal Coverage true See on this page: Coverage/coverage1001 total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
Value Currency 200 USD ProcessNotes
Extension Text processNote disclaimer text benefitPeriod: 2022-01-01 --> 2022-01-01
benefitBalance
category: Medical Care (X12 Service Type Codes#1)
unit: Individual (Unit Type Codes#individual)
term: Annual (Benefit Term Codes#annual)
Financials
Extension Type Allowed[x] Used[x] Allowed (PCT Financial Type Code System#allowed) $1.00 (USD) $1.00 (USD)
Entry 2 - fullUrl = http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1
Resource ExplanationOfBenefit:
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PCT-AEOB-1"
Profile: PCT Advanced EOB
GFE Reference: See on this page: Bundle/PCT-GFE-Bundle-Inst-1
Service Description: Example service
In Network Provider Options Link: http://example.com/out-of-network.html
identifier: Unique Claim ID/?ngen-9?
status: ACTIVE
type: Institutional (Claim Type Codes#institutional)
use: PREDETERMINATION
patient: See on this page: Patient/patient1001
created: 2021-10-12
insurer: See on this page: Organization/org1001
provider: Organization/org1002 "Boston Radiology Center"
priority: Normal (Process Priority Codes#normal)
claim:
http://example.com/identifiers/bundle/59688475-2324-3242-23473847outcome: COMPLETE
Insurances
Focal Coverage true See on this page: Coverage/coverage1001 item
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
serviced: 2022-01-01
Nets
Value Currency 200 USD Adjudications
Extension Category Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement) Adjudications
Extension Category Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement) Submitted Amount (Adjudication Value Codes#submitted) Member Liability (PCT Adjudication Category CodeSystem#memberliability) total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
Value Currency 200 USD ProcessNotes
Extension Text processNote disclaimer text benefitPeriod: 2022-01-01 --> 2023-01-01
benefitBalance
category: Medical Care (X12 Service Type Codes#1)
unit: Individual (Unit Type Codes#individual)
term: Annual (Benefit Term Codes#annual)
Financials
Extension Type Allowed[x] Used[x] Allowed (PCT Financial Type Code System#allowed) $1.00 (USD) $1.00 (USD)
Entry 3 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf female, DoB: 1955-07-23 (
http://example.com/identifiers/patient/1001)
Marital Status: unmarried Contact Details:
- ph: 781-949-4949(MOBILE)
- 222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)
Entry 4 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:
Resource Coverage "coverage1001"
Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: active
subscriberId: PFP123450000
beneficiary: Patient/patient1001 " BETTERHALF"
relationship: Self (SubscriberPolicyholder Relationship Codes#self)
period: 2021-01-01 --> 2022-01-01
payor: Organization/org1001 "Umbrella Insurance Company"
Classes
Type Value Name Plan (Coverage Class Codes#plan) Premim Family Plus Premim Family Plus Plan CostToBeneficiaries
Type Value[x] Copay Percentage (Coverage Copay Type Codes#copaypct) 20
Entry 5 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:
Resource Organization "org1001"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer (Organization type#pay)
name: Umbrella Insurance Company
telecom: ph: 860-547-5001(WORK)
address: 680 Asylum Street Hartford CT 06155 US
Entry 6 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1
Resource Bundle:
Bundle PCT-GFE-Bundle-Inst-1 of type collection
Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-1
Resource Claim:
Resource Claim "PCT-GFE-Summary-1"
Profile: PCT Good Faith Estimate Summary
status: active
type: Estimate Summary (PCT Estimate Type Code System#estimate-summary)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
billablePeriod: 2021-10-31 --> 2021-10-31
created: 2021-10-05
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: ??
priority: Normal (Process Priority Codes#normal)
Diagnoses
Sequence Diagnosis[x] Type PackageCode 1 Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30) Principal Diagnosis (Example Diagnosis Type Codes#principal) Head trauma - concussion (Example Diagnosis Related Group Codes#400) Insurances
Sequence Focal Coverage 1 true Coverage/coverage1001 Totals
Value Currency 200 USD Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Institutional-1
Resource Claim:
Resource Claim "PCT-GFE-Institutional-1"
ProviderEventMethodology: EEMM1021
GFEDisclaimer: For estimation purposes only
GFEServiceLinkingInfo
url
linkingIdentifiervalue: 223452-2342-2435-008001
url
plannedPeriodOfServicevalue: 2021-10-31
identifier: Placer Identifier/GFEProviderAssignedID0001
status: active
type: Institutional (Claim Type Codes#institutional)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
created: 2021-10-05
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: Organization/Submitter-Org-1 "GFE Service Help INC."
priority: Normal (Process Priority Codes#normal)
Payees
Type Provider (Payee Type Codes#provider) referral: : Referral Number
SupportingInfos
Sequence Category Code 1 Type of Bill (PCT GFE Supporting Info Type Code System#typeofbill) Hospital Inpatient (Part A) (AHA NUBC Type Of Bill Codes#011X) Diagnoses
Sequence Diagnosis[x] Type PackageCode 1 Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30) Principal Diagnosis (Example Diagnosis Type Codes#principal) Head trauma - concussion (Example Diagnosis Related Group Codes#400) Insurances
Sequence Focal Coverage 1 true Coverage/coverage1001 item
Service Description: Imaging
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
serviced: 2021-10-31
quantity: 1
Nets
Value Currency 200 USD Totals
Value Currency 200 USD Entry 3 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1
Resource Organization:
Resource Organization "Submitter-Org-1"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-10010301
active: true
type: Non-Healthcare Business or Corporation (Organization type#bus)
name: GFE Service Help INC.
Contacts
Purpose Name Telecom GFE-related (PCT Organization Contact Purpose Type Code System#GFERELATED) Clara Sender ph: 781-632-3209(WORK), csender@GFEServiceHelp.com Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:
Resource Organization "org1001"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer (Organization type#pay)
name: Umbrella Insurance Company
telecom: ph: 860-547-5001(WORK)
address: 680 Asylum Street Hartford CT 06155 US
Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf female, DoB: 1955-07-23 (
http://example.com/identifiers/patient/1001)
Marital Status: unmarried Contact Details:
- ph: 781-949-4949(MOBILE)
- 222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred) Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:
Resource Coverage "coverage1001"
Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: active
subscriberId: PFP123450000
beneficiary: Patient/patient1001 " BETTERHALF"
relationship: Self (SubscriberPolicyholder Relationship Codes#self)
period: 2021-01-01 --> 2022-01-01
payor: Organization/org1001 "Umbrella Insurance Company"
Classes
Type Value Name Plan (Coverage Class Codes#plan) Premim Family Plus Premim Family Plus Plan CostToBeneficiaries
Type Value[x] Copay Percentage (Coverage Copay Type Codes#copaypct) 20
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-08
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