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

: PCT-GFE-Institutional-MRI - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "PCT-GFE-Institutional-MRI",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"PCT-GFE-Institutional-MRI\"> </a><a name=\"hcPCT-GFE-Institutional-MRI\"> </a></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 Claim &quot;PCT-GFE-Institutional-MRI&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-institutional.html\">PCT Good Faith Estimate Institutional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1021</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008002</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2022-02-02</p></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001MRI</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/5.3.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>created</b>: 2022-02-02</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization/Submitter-Org-1</a> &quot;GFE Service Help INC.&quot;</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html\">Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Type of Bill <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTSupportingInfoType.html\">PCT GFE Supporting Info Type Code System</a>#typeofbill)</span></td><td>example-bill-type <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCTypeOfBill.html\">AHA NUBC Type Of Bill Codes</a>#example-bill-type)</span></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html\">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</p><p><b>sequence</b>: 1</p><p><b>revenue</b>: Magnetic Resonance Technology (MRT) - Brain/brain stem <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#0611)</span></p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>serviced</b>: 2022-02-02</p><p><b>quantity</b>: 1</p><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>266</td><td>USD</td></tr></table></blockquote><h3>Totals</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>266</td><td>USD</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
      "valueString" : "EEMM1021"
    },
    {
      "extension" : [
        {
          "url" : "linkingIdentifier",
          "valueString" : "223452-2342-2435-008002"
        },
        {
          "url" : "plannedPeriodOfService",
          "valueDate" : "2022-02-02"
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
    }
  ],
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "PLAC",
            "display" : "Placer Identifier"
          }
        ]
      },
      "value" : "GFEProviderAssignedID0001MRI"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional",
        "display" : "Institutional"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    🔗 "reference" : "Patient/patient1001"
  },
  "created" : "2022-02-02",
  "insurer" : {
    🔗 "reference" : "Organization/org1001"
  },
  "provider" : {
    🔗 "extension" : [
      {
        "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy",
        "valueCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://nucc.org/provider-taxonomy",
              "code" : "2085D0003X",
              "display" : "Diagnostic Neuroimaging (Radiology) Physician"
            }
          ]
        }
      }
    ],
    "reference" : "Organization/Submitter-Org-1"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    }
  },
  "referral" : {
    "extension" : [
      {
        "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber",
        "valueString" : "REF12022002-122"
      }
    ],
    "display" : "Referral Number"
  },
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType",
            "code" : "typeofbill"
          }
        ]
      },
      "code" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/TypeOfBill",
            "code" : "example-bill-type"
          }
        ]
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10-cm",
            "code" : "S06.30",
            "display" : "Unspecified focal traumatic brain injury"
          }
        ]
      },
      "type" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code" : "principal"
            }
          ]
        }
      ],
      "packageCode" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
            "code" : "400",
            "display" : "Head trauma - concussion"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/coverage1001"
      }
    }
  ],
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
          "valueString" : "Imaging"
        }
      ],
      "sequence" : 1,
      "revenue" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
            "code" : "0611",
            "display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem"
          }
        ]
      },
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.ama-assn.org/go/cpt",
            "code" : "70551",
            "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
          }
        ]
      },
      "servicedDate" : "2022-02-02",
      "quantity" : {
        "value" : 1
      },
      "net" : {
        "value" : 266,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 266,
    "currency" : "USD"
  }
}