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 - XML Representation

Page standards status: Informative

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="PCT-AEOB-Summary-1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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>
  </text>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
    <valueString value="Example service"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink">
    <valueUrl value="http://example.com/out-of-network.html"/>
  </extension>
  <status value="active"/>
  <type>
    <coding>
      <system
              value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
      <code value="estimate-summary"/>
      <display value="Estimate Summary"/>
    </coding>
  </type>
  <use value="predetermination"/>
  <patient>🔗 
    <reference value="Patient/patient1001"/>
  </patient>
  <billablePeriod>
    <start value="2022-01-01"/>
    <end value="2022-01-01"/>
  </billablePeriod>
  <created value="2021-10-12"/>
  <insurer>🔗 
    <reference value="Organization/org1001"/>
  </insurer>
  <provider>
    <extension
               url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
      <valueCode value="not-applicable"/>
    </extension>
  </provider>
  <outcome value="complete"/>
  <insurance>
    <focal value="true"/>
    <coverage>🔗 
      <reference value="Coverage/coverage1001"/>
    </coverage>
  </insurance>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
    </category>
    <amount>
      <value value="200"/>
      <currency value="USD"/>
    </amount>
  </total>
  <processNote>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS"/>
          <code value="disclaimer"/>
          <display value="Disclaimer"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text value="processNote disclaimer text"/>
  </processNote>
  <benefitPeriod>
    <start value="2022-01-01"/>
    <end value="2022-01-01"/>
  </benefitPeriod>
  <benefitBalance>
    <category>
      <coding>
        <system value="https://x12.org/codes/service-type-codes"/>
        <code value="1"/>
        <display value="Medical Care"/>
      </coding>
    </category>
    <unit>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
        <code value="individual"/>
      </coding>
    </unit>
    <term>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
        <code value="annual"/>
      </coding>
    </term>
    <financial>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit">
        <valueMoney>
          <value value="0"/>
          <currency value="USD"/>
        </valueMoney>
      </extension>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"/>
          <code value="allowed"/>
        </coding>
      </type>
      <allowedMoney>
        <value value="1"/>
        <currency value="USD"/>
      </allowedMoney>
      <usedMoney>
        <value value="1"/>
        <currency value="USD"/>
      </usedMoney>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>