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-AEOB-Summary-1 - JSON Representation

Page standards status: Informative

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "PCT-AEOB-Summary-1",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"PCT-AEOB-Summary-1\"> </a><a name=\"hcPCT-AEOB-Summary-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 &quot;PCT-AEOB-Summary-1&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob-summary.html\">PCT Advanced EOB Summary</a></p></div><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>status</b>: active</p><p><b>type</b>: Estimate Summary <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTEstimateTypeSummaryCSTemporaryTrialUse.html\">PCT Estimate Type Code System</a>#estimate-summary)</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>billablePeriod</b>: 2022-01-01 --&gt; 2022-01-01</p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <span>??</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>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 --&gt; 2022-01-01</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/serviceDescription",
      "valueString" : "Example service"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
      "valueUrl" : "http://example.com/out-of-network.html"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
        "code" : "estimate-summary",
        "display" : "Estimate Summary"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    🔗 "reference" : "Patient/patient1001"
  },
  "billablePeriod" : {
    "start" : "2022-01-01",
    "end" : "2022-01-01"
  },
  "created" : "2021-10-12",
  "insurer" : {
    🔗 "reference" : "Organization/org1001"
  },
  "provider" : {
    "extension" : [
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
        "valueCode" : "not-applicable"
      }
    ]
  },
  "outcome" : "complete",
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/coverage1001"
      }
    }
  ],
  "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" : "2022-01-01"
  },
  "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"
          }
        }
      ]
    }
  ]
}