Patient Cost Transparency Implementation Guide
1.1.0 - STU 1 United States of America flag

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

: PCT-AEOB-Bundle-1 - JSON Representation

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{
  "resourceType" : "Bundle",
  "id" : "PCT-AEOB-Bundle-1",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle"
    ]
  },
  "identifier" : {
    "system" : "http://example.com/identifiers/bundle",
    "value" : "59688475-2324-3242-1234567"
  },
  "type" : "collection",
  "timestamp" : "2021-11-10T11:01:00+05:00",
  "entry" : [
    {
      "fullUrl" : "http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1",
      "resource" : {
        "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></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-1&quot; </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:\u00a0?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\">See above (Patient/patient1001)</a></p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href=\"#Organization_org1001\">See above (Organization/org1001)</a></p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Organization/org1002</a> &quot;Boston Radiology Center&quot;</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>id:\u00a059688475-2324-3242-23473847</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\">See above (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 --&gt; 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\">US$1.00</span> (USD)</td><td><span title=\"US Dollar\">US$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"
                }
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Patient/patient1001",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "patient1001",
        "meta" : {
          "profile" : [
            🔗 "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Patient</b><a name=\"patient1001\"> </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 Patient &quot;patient1001&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"http://hl7.org/fhir/us/davinci-hrex/STU1/StructureDefinition-hrex-patient-demographics.html\">HRex Patient Demographics</a></p></div><p><b>identifier</b>: id:\u00a01001</p><p><b>name</b>: Eve Betterhalf</p><p><b>telecom</b>: ph: 781-949-4949(MOBILE)</p><p><b>gender</b>: female</p><p><b>birthDate</b>: 1955-07-23</p><p><b>address</b>: 222 Burlington Road, Bedford MA 01730</p><p><b>maritalStatus</b>: unmarried <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-MaritalStatus.html\">MaritalStatus</a>#U)</span></p><h3>Communications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Language</b></td><td><b>Preferred</b></td></tr><tr><td style=\"display: none\">*</td><td>English (United States) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-v3-ietf3066.html\">Tags for the Identification of Languages</a>#en-US)</span></td><td>true</td></tr></table></div>"
        },
        "identifier" : [
          {
            "system" : "http://example.com/identifiers/patient",
            "value" : "1001"
          }
        ],
        "name" : [
          {
            "text" : "Eve Betterhalf",
            "family" : "Betterhalf",
            "given" : [
              "Eve"
            ]
          }
        ],
        "telecom" : [
          {
            "system" : "phone",
            "value" : "781-949-4949",
            "use" : "mobile"
          }
        ],
        "gender" : "female",
        "birthDate" : "1955-07-23",
        "address" : [
          {
            "text" : "222 Burlington Road, Bedford MA 01730"
          }
        ],
        "maritalStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
              "code" : "U",
              "display" : "unmarried"
            }
          ]
        },
        "communication" : [
          {
            "language" : {
              "coding" : [
                {
                  "system" : "urn:ietf:bcp:47",
                  "code" : "en-US",
                  "display" : "English (United States)"
                }
              ]
            },
            "preferred" : true
          }
        ]
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Coverage/coverage1001",
      "resource" : {
        "resourceType" : "Coverage",
        "id" : "coverage1001",
        "meta" : {
          "profile" : [
            🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Coverage</b><a name=\"coverage1001\"> </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 Coverage &quot;coverage1001&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-coverage.html\">PCT Coverage</a></p></div><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href=\"#Patient_patient1001\">See above (Patient/patient1001)</a></p><p><b>relationship</b>: Self <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html\">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --&gt; 2022-01-01</p><p><b>payor</b>: <a href=\"#Organization_org1001\">See above (Organization/org1001)</a></p><h3>Classes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style=\"display: none\">*</td><td>Plan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>Copay Percentage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html\">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>"
        },
        "status" : "active",
        "subscriberId" : "PFP123450000",
        "beneficiary" : {
          🔗 "reference" : "Patient/patient1001"
        },
        "relationship" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
              "code" : "self",
              "display" : "Self"
            }
          ]
        },
        "period" : {
          "start" : "2021-01-01",
          "end" : "2022-01-01"
        },
        "payor" : [
          {
            🔗 "reference" : "Organization/org1001"
          }
        ],
        "class" : [
          {
            "type" : {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code" : "plan",
                  "display" : "Plan"
                }
              ]
            },
            "value" : "Premim Family Plus",
            "name" : "Premim Family Plus Plan"
          }
        ],
        "costToBeneficiary" : [
          {
            "type" : {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
                  "code" : "copaypct",
                  "display" : "Copay Percentage"
                }
              ]
            },
            "valueQuantity" : {
              "value" : 20
            }
          }
        ]
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Organization/org1001",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "org1001",
        "meta" : {
          "profile" : [
            🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"org1001\"> </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 Organization &quot;org1001&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-organization.html\">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number:\u00a0ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html\">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US </p></div>"
        },
        "identifier" : [
          {
            "type" : {
              "coding" : [
                {
                  "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS",
                  "code" : "ETIN"
                }
              ]
            },
            "value" : "ETIN-3200002"
          }
        ],
        "active" : true,
        "type" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/organization-type",
                "code" : "pay",
                "display" : "Payer"
              }
            ]
          }
        ],
        "name" : "Umbrella Insurance Company",
        "telecom" : [
          {
            "system" : "phone",
            "value" : "860-547-5001",
            "use" : "work"
          }
        ],
        "address" : [
          {
            "extension" : [
              {
                "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode",
                "valueCoding" : {
                  "system" : "urn:iso:std:iso:3166:-2",
                  "code" : "US-CT"
                }
              }
            ],
            "line" : [
              "680 Asylum Street"
            ],
            "city" : "Hartford",
            "state" : "CT",
            "postalCode" : "06155",
            "country" : "US"
          }
        ]
      }
    }
  ]
}