Patient Cost Transparency Implementation Guide
1.1.0 - STU 1
Patient Cost Transparency Implementation Guide
1.1.0 - STU 1
This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v1.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Bundle PCT-AEOB-Bundle-1 of type collection
Entry 1 - fullUrl = http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1
Resource ExplanationOfBenefit:
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PCT-AEOB-1"
Profile: PCT Advanced EOB
GFE Reference: Bundle/PCT-GFE-Bundle-Inst-1
Service Description: Example service
In Network Provider Options Link: http://example.com/out-of-network.html
identifier: Unique Claim ID: ?ngen-9?
status: ACTIVE
type: Institutional (Claim Type Codes#institutional)
use: PREDETERMINATION
patient: See above (Patient/patient1001)
created: 2021-10-12
insurer: See above (Organization/org1001)
provider: Organization/org1002 "Boston Radiology Center"
priority: Normal (Process Priority Codes#normal)
claim: id: 59688475-2324-3242-23473847
outcome: COMPLETE
Insurances
Focal Coverage true See above (Coverage/coverage1001) item
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
serviced: 2022-01-01
Nets
Value Currency 200 USD Adjudications
Extension Category Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement) Adjudications
Extension Category Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement) Submitted Amount (Adjudication Value Codes#submitted) Member Liability (PCT Adjudication Category CodeSystem#memberliability) total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
Value Currency 200 USD ProcessNotes
Extension Text processNote disclaimer text benefitPeriod: 2022-01-01 --> 2023-01-01
benefitBalance
category: Medical Care (X12 Service Type Codes#1)
unit: Individual (Unit Type Codes#individual)
term: Annual (Benefit Term Codes#annual)
Financials
Extension Type Allowed[x] Used[x] Allowed (PCT Financial Type Code System#allowed) US$1.00 (USD) US$1.00 (USD)
Entry 2 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf Female, DoB: 1955-07-23 ( id: 1001)
Entry 3 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:
Resource Coverage "coverage1001"
Profile: PCT Coverage
status: ACTIVE
subscriberId: id: PFP123450000
beneficiary: See above (Patient/patient1001)
relationship: Self (SubscriberPolicyholder Relationship Codes#self)
period: 2021-01-01 --> 2022-01-01
Classes
Type Value Name Plan (Coverage Class Codes#plan) id: Premim Family Plus Premim Family Plus Plan CostToBeneficiaries
Type Value[x] Copay Percentage (Coverage Copay Type Codes#copaypct) 20
Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:
Generated Narrative: Organization
Resource Organization "org1001"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number: ETIN-3200002
active: true
type: Payer (Organization type#pay)
name: Umbrella Insurance Company
Contacts
Telecom Address ph: 860-547-5001(WORK) 680 Asylum Street Hartford CT 06155 US
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#1.1.0 based on FHIR 4.0.1. Generated 2024-01-03
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