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 Claim: PCT-GFE-Summary-MRI

Page standards status: Informative

Generated Narrative: Claim

Resource Claim "PCT-GFE-Summary-MRI"

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 --> (ongoing)

created: 2021-10-05

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: ??

priority: Normal (Process Priority Codes#normal)

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified 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

-SequenceFocalCoverage
*1trueCoverage/coverage1001

Totals

-ValueCurrency
*200USD