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

Example Bundle: PCT-GFE-Collection-Bundle-1

Bundle PCT-GFE-Collection-Bundle-1 of type collection

Entry 1 - 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 2 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource 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

-TypeValueName
*Plan (Coverage Class Codes#plan)Premim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage (Coverage Copay Type Codes#copaypct)20

Entry 3 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1

Resource 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

-PurposeNameTelecom
*GFE-related (PCT Organization Contact Purpose Type Code System#GFERELATED)Clara Senderph: 781-632-3209(WORK), csender@GFEServiceHelp.com

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001

Resource 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/Bundle/PCT-GFE-Missing-Bundle-1

Resource Bundle:

Bundle PCT-GFE-Missing-Bundle-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Organization/org1002

Resource Organization:

identifier: National provider identifier/1234568095, Tax ID number/TAX-3211001

active: true

type: Healthcare Provider (Organization type#prov)

name: Boston Radiology Center

telecom: ph: 781-232-3200(WORK)

address: 32 Fruit Street Boston MA 02114 US

Entry 2 - 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 3 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource 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

-TypeValueName
*Plan (Coverage Class Codes#plan)Premim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage (Coverage Copay Type Codes#copaypct)20

Entry 4 - fullUrl = http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1

Resource DeviceRequest:

status: active

intent: proposal

code: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (HCPCSReleaseCodeSets#L1820)

subject: Patient/patient1001 " BETTERHALF"