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
| Page standards status: Informative |
{
"resourceType" : "ExplanationOfBenefit",
"id" : "PCT-AEOB-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"PCT-AEOB-1\"> </a><a name=\"hcPCT-AEOB-1\"> </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 ExplanationOfBenefit "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>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href=\"http://example.com/out-of-network.html\">http://example.com/out-of-network.html</a></p><p><b>identifier</b>: Unique Claim ID/?ngen-9?</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> " 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/5.3.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>claim</b>: <span><code>http://example.com/identifiers/bundle</code>/59688475-2324-3242-23473847</span></p><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></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>modifier</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>: 2022-01-01</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>200</td><td>USD</td></tr></table><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>Medical Management <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTAdjudicationCategoryCS.html\">PCT Adjudication Category CodeSystem</a>#medicalmanagement)</span></td></tr></table></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>Medical Management <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTAdjudicationCategoryCS.html\">PCT Adjudication Category CodeSystem</a>#medicalmanagement)</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td>Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td>Member Liability <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTAdjudicationCategoryCS.html\">PCT Adjudication Category CodeSystem</a>#memberliability)</span></td></tr></table><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/5.3.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</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>200</td><td>USD</td></tr></table></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --> 2023-01-01</p><blockquote><p><b>benefitBalance</b></p><p><b>category</b>: Medical Care <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-X12ServiceTypeCodes.html\">X12 Service Type Codes</a>#1)</span></p><p><b>unit</b>: Individual <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-benefit-unit.html\">Unit Type Codes</a>#individual)</span></p><p><b>term</b>: Annual <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-benefit-term.html\">Benefit Term Codes</a>#annual)</span></p><h3>Financials</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>Allowed <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTFinancialType.html\">PCT Financial Type Code System</a>#allowed)</span></td><td><span title=\"US Dollar\">$1.00</span> (USD)</td><td><span title=\"US Dollar\">$1.00</span> (USD)</td></tr></table></blockquote></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
"valueReference" : {
🔗 "reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString" : "Example service"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
"valueUrl" : "http://example.com/out-of-network.html"
}
],
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
"code" : "uc",
"display" : "Unique Claim ID"
}
]
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional",
"display" : "Institutional"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/patient1001"
},
"created" : "2021-10-12",
"insurer" : {
🔗 "reference" : "Organization/org1001"
},
"provider" : {
🔗 "reference" : "Organization/org1002"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"claim" : {
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-23473847"
}
},
"outcome" : "complete",
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/coverage1001"
}
}
],
"item" : [
{
"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"
}
]
},
"modifier" : [
{
"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" : "2022-01-01",
"net" : {
"value" : 200,
"currency" : "USD"
},
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "medicalmanagement",
"display" : "Medical Management"
}
]
}
}
]
}
],
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "medicalmanagement",
"display" : "Medical Management"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "memberliability",
"display" : "Member Liability"
}
]
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
}
],
"processNote" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
"code" : "disclaimer",
"display" : "Disclaimer"
}
]
}
}
],
"text" : "processNote disclaimer text"
}
],
"benefitPeriod" : {
"start" : "2022-01-01",
"end" : "2023-01-01"
},
"benefitBalance" : [
{
"category" : {
"coding" : [
{
"system" : "https://x12.org/codes/service-type-codes",
"code" : "1",
"display" : "Medical Care"
}
]
},
"unit" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
"code" : "individual"
}
]
},
"term" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
"code" : "annual"
}
]
},
"financial" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
"valueMoney" : {
"value" : 0,
"currency" : "USD"
}
}
],
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"code" : "allowed"
}
]
},
"allowedMoney" : {
"value" : 1,
"currency" : "USD"
},
"usedMoney" : {
"value" : 1,
"currency" : "USD"
}
}
]
}
]
}
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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