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
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Bundle ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "PCT-AEOB-Bundle-1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle> ] ) ] ; # fhir:identifier [ fhir:system [ fhir:v "http://example.com/identifiers/bundle"^^xsd:anyURI ] ; fhir:value [ fhir:v "59688475-2324-3242-1234567" ] ] ; # fhir:type [ fhir:v "collection"] ; # fhir:timestamp [ fhir:v "2021-11-10T11:01:00+05:00"^^xsd:dateTime] ; # fhir:entry ( [ fhir:fullUrl [ fhir:v "http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1> ) ] [ fhir:fullUrl [ fhir:v "http://example.org/fhir/Patient/patient1001"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Patient/patient1001> ) ] [ fhir:fullUrl [ fhir:v "http://example.org/fhir/Coverage/coverage1001"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Coverage/coverage1001> ) ] [ fhir:fullUrl [ fhir:v "http://example.org/fhir/Organization/org1001"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Organization/org1001> ) ] ) . # <http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1> a fhir:ExplanationOfBenefit ; fhir:id [ fhir:v "PCT-AEOB-1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir: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 "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\">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> "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>id: 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\">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 --> 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>" ] ; # fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference"^^xsd:anyURI ] ; fhir:value [ a fhir:Reference ; fhir:reference [ fhir:v "Bundle/PCT-GFE-Bundle-Inst-1" ] ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription"^^xsd:anyURI ] ; fhir:value [ fhir:v "Example service" ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink"^^xsd:anyURI ] ; fhir:value [ fhir:v "http://example.com/out-of-network.html"^^xsd:anyURI ] ] ) ; # fhir:identifier ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType"^^xsd:anyURI ] ; fhir:code [ fhir:v "uc" ] ; fhir:display [ fhir:v "Unique Claim ID" ] ] ) ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "institutional" ] ; fhir:display [ fhir:v "Institutional" ] ] ) ] ; # fhir:use [ fhir:v "predetermination"] ; # fhir:patient [ fhir:reference [ fhir:v "Patient/patient1001" ] ] ; # fhir:created [ fhir:v "2021-10-12"^^xsd:date] ; # fhir:insurer [ fhir:reference [ fhir:v "Organization/org1001" ] ] ; # fhir:provider [ fhir:reference [ fhir:v "Organization/org1002" ] ] ; # fhir:priority [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ; fhir:code [ fhir:v "normal" ] ] ) ] ; # fhir:claim [ fhir:identifier [ fhir:system [ fhir:v "http://example.com/identifiers/bundle"^^xsd:anyURI ] ; fhir:value [ fhir:v "59688475-2324-3242-23473847" ] ] ] ; # fhir:outcome [ fhir:v "complete"] ; # fhir:insurance ( [ fhir:focal [ fhir:v "true"^^xsd:boolean ] ; fhir:coverage [ fhir:reference [ fhir:v "Coverage/coverage1001" ] ] ] ) ; # fhir:item ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:revenue [ ( fhir:coding [ fhir:system [ fhir:v "https://www.nubc.org/CodeSystem/RevenueCodes"^^xsd:anyURI ] ; fhir:code [ fhir:v "0611" ] ; fhir:display [ fhir:v "Magnetic Resonance Technology (MRT) - Brain/brain stem" ] ] ) ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "70551" ] ; fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ) ] ; ( fhir:modifier [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "70551" ] ; fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ) ] ) ; fhir:serviced [ fhir:v "2022-01-01"^^xsd:date ] ; fhir:net [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; ( fhir:adjudication [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt"^^xsd:anyURI ] ; fhir:value [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "concurrent-review" ] ; fhir:display [ fhir:v "Concurrent Review" ] ] ) ] ] ) ; fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "medicalmanagement" ] ; fhir:display [ fhir:v "Medical Management" ] ] ) ] ] ) ] ) ; # fhir:adjudication ( [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt"^^xsd:anyURI ] ; fhir:value [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "concurrent-review" ] ; fhir:display [ fhir:v "Concurrent Review" ] ] ) ] ] ) ; fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "medicalmanagement" ] ; fhir:display [ fhir:v "Medical Management" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ] [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "memberliability" ] ; fhir:display [ fhir:v "Member Liability" ] ] ) ] ] ) ; # fhir:total ( [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ; fhir:code [ fhir:v "submitted" ] ; fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ; fhir:amount [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ; # fhir:processNote ( [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass"^^xsd:anyURI ] ; fhir:value [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "disclaimer" ] ; fhir:display [ fhir:v "Disclaimer" ] ] ) ] ] ) ; fhir:text [ fhir:v "processNote disclaimer text" ] ] ) ; # fhir:benefitPeriod [ fhir:start [ fhir:v "2022-01-01"^^xsd:date ] ; fhir:end [ fhir:v "2023-01-01"^^xsd:date ] ] ; # fhir:benefitBalance ( [ fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "https://x12.org/codes/service-type-codes"^^xsd:anyURI ] ; fhir:code [ fhir:v "1" ] ; fhir:display [ fhir:v "Medical Care" ] ] ) ] ; fhir:unit [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/benefit-unit"^^xsd:anyURI ] ; fhir:code [ fhir:v "individual" ] ] ) ] ; fhir:term [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/benefit-term"^^xsd:anyURI ] ; fhir:code [ fhir:v "annual" ] ] ) ] ; ( fhir:financial [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit"^^xsd:anyURI ] ; fhir:value [ a fhir:Money ; fhir:value [ fhir:v "0"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ; fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"^^xsd:anyURI ] ; fhir:code [ fhir:v "allowed" ] ] ) ] ; fhir:allowed [ a fhir:Money ; fhir:value [ fhir:v "1"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ; fhir:used [ a fhir:Money ; fhir:value [ fhir:v "1"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ] ) . # <http://example.org/fhir/Patient/patient1001> a fhir:Patient ; fhir:id [ fhir:v "patient1001"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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 "patient1001" </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: 1001</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>" ] ; # fhir:identifier ( [ fhir:system [ fhir:v "http://example.com/identifiers/patient"^^xsd:anyURI ] ; fhir:value [ fhir:v "1001" ] ] ) ; # fhir:name ( [ fhir:text [ fhir:v "Eve Betterhalf" ] ; fhir:family [ fhir:v "Betterhalf" ] ; ( fhir:given [ fhir:v "Eve" ] ) ] ) ; # fhir:telecom ( [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "781-949-4949" ] ; fhir:use [ fhir:v "mobile" ] ] ) ; # fhir:gender [ fhir:v "female"] ; # fhir:birthDate [ fhir:v "1955-07-23"^^xsd:date] ; # fhir:address ( [ fhir:text [ fhir:v "222 Burlington Road, Bedford MA 01730" ] ] ) ; # fhir:maritalStatus [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "U" ] ; fhir:display [ fhir:v "unmarried" ] ] ) ] ; # fhir:communication ( [ fhir:language [ ( fhir:coding [ fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ; fhir:code [ fhir:v "en-US" ] ; fhir:display [ fhir:v "English (United States)" ] ] ) ] ; fhir:preferred [ fhir:v "true"^^xsd:boolean ] ] ) . # <http://example.org/fhir/Coverage/coverage1001> a fhir:Coverage ; fhir:id [ fhir:v "coverage1001"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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 "coverage1001" </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 --> 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>" ] ; # fhir:status [ fhir:v "active"] ; # fhir:subscriberId [ fhir:v "PFP123450000"] ; # fhir:beneficiary [ fhir:reference [ fhir:v "Patient/patient1001" ] ] ; # fhir:relationship [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/subscriber-relationship"^^xsd:anyURI ] ; fhir:code [ fhir:v "self" ] ; fhir:display [ fhir:v "Self" ] ] ) ] ; # fhir:period [ fhir:start [ fhir:v "2021-01-01"^^xsd:date ] ; fhir:end [ fhir:v "2022-01-01"^^xsd:date ] ] ; # fhir:payor ( [ fhir:reference [ fhir:v "Organization/org1001" ] ] ) ; # fhir:class ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ; fhir:code [ fhir:v "plan" ] ; fhir:display [ fhir:v "Plan" ] ] ) ] ; fhir:value [ fhir:v "Premim Family Plus" ] ; fhir:name [ fhir:v "Premim Family Plus Plan" ] ] ) ; # fhir:costToBeneficiary ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "copaypct" ] ; fhir:display [ fhir:v "Copay Percentage" ] ] ) ] ; fhir:value [ a fhir:Quantity ; fhir:value [ fhir:v "20"^^xsd:decimal ] ] ] ) . # <http://example.org/fhir/Organization/org1001> a fhir:Organization ; fhir:id [ fhir:v "org1001"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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 "org1001" </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: ETIN-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>" ] ; # fhir:identifier ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "ETIN" ] ] ) ] ; fhir:value [ fhir:v "ETIN-3200002" ] ] ) ; # fhir:active [ fhir:v "true"^^xsd:boolean] ; # fhir:type ( [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/organization-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "pay" ] ; fhir:display [ fhir:v "Payer" ] ] ) ] ) ; # fhir:name [ fhir:v "Umbrella Insurance Company"] ; # fhir:telecom ( [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "860-547-5001" ] ; fhir:use [ fhir:v "work" ] ] ) ; # fhir:address ( [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode"^^xsd:anyURI ] ; fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "urn:iso:std:iso:3166:-2"^^xsd:anyURI ] ; fhir:code [ fhir:v "US-CT" ] ] ] ) ; ( fhir:line [ fhir:v "680 Asylum Street" ] ) ; fhir:city [ fhir:v "Hartford" ] ; fhir:state [ fhir:v "CT" ] ; fhir:postalCode [ fhir:v "06155" ] ; fhir:country [ fhir:v "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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