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-GFE-Bundle-Prof-1 - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="PCT-GFE-Bundle-Prof-1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
  </meta>
  <identifier>
    <system value="http://example.com/identifiers/bundle"/>
    <value value="59688475-2324-3242-23473847"/>
  </identifier>
  <type value="collection"/>
  <timestamp value="2021-11-09T11:01:00+05:00"/>
  <entry id="PCT-GFE-Professional-MRI">
    <fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Professional-MRI"/>
    <resource>
      <Claim>
        <id value="PCT-GFE-Professional-MRI"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"/>
        </meta>
        <text>
          <status value="extensions"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="PCT-GFE-Professional-MRI"> </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 Claim &quot;PCT-GFE-Professional-MRI&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-gfe-professional.html">PCT Good Faith Estimate Professional</a></p></div><p><b>GFESubmitter</b>: <a href="#Practitioner_Submitter-Practitioner-1">See above (Practitioner/Submitter-Practitioner-1)</a></p><p><b>ProviderEventMethodology</b>: EEMM1022</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008001</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2021-10-31</p></blockquote><p><b>identifier</b>: Placer Identifier: GFEProviderAssignedID0002</p><p><b>status</b>: active</p><p><b>type</b>: Professional <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>#professional)</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>: 2021-10-05</p><p><b>insurer</b>: <a href="#Organization_org1001">See above (Organization/org1001)</a></p><p><b>provider</b>: <a href="#Practitioner_Submitter-Practitioner-1">See above (Practitioner/Submitter-Practitioner-1)</a></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><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html">Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</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>Service Description</b>: Imaging</p><p><b>GFEBillingProviderLineItemCtrlNum</b>: id: GFEBillingProviderLineItemCtrlNum-0001</p><p><b>sequence</b>: 1</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>: 2021-10-31</p><p><b>location</b>: Inpatient Hospital <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#21)</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</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>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></blockquote><h3>Totals</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></div>
        </text>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter">
          <valueReference>🔗 
            <reference value="Practitioner/Submitter-Practitioner-1"/>
          </valueReference>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
          <valueString value="EEMM1022"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
          <extension url="linkingIdentifier">
            <valueString value="223452-2342-2435-008001"/>
          </extension>
          <extension url="plannedPeriodOfService">
            <valueDate value="2021-10-31"/>
          </extension>
        </extension>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="PLAC"/>
              <display value="Placer Identifier"/>
            </coding>
          </type>
          <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
          <value value="GFEProviderAssignedID0002"/>
        </identifier>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="professional"/>
            <display value="Professional"/>
          </coding>
        </type>
        <use value="predetermination"/>
        <patient>🔗 
          <reference value="Patient/patient1001"/>
        </patient>
        <created value="2021-10-05"/>
        <insurer>🔗 
          <reference value="Organization/org1001"/>
        </insurer>
        <provider>🔗 
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
            <valueCodeableConcept>
              <coding>
                <system value="http://nucc.org/provider-taxonomy"/>
                <code value="2085D0003X"/>
                <display
                         value="Diagnostic Neuroimaging (Radiology) Physician"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <reference value="Practitioner/Submitter-Practitioner-1"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
          </coding>
        </priority>
        <payee>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/payeetype"/>
              <code value="provider"/>
            </coding>
          </type>
        </payee>
        <referral>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
            <valueString value="REF12022002-122"/>
          </extension>
          <display value="Referral Number"/>
        </referral>
        <diagnosis>
          <sequence value="1"/>
          <diagnosisCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
              <code value="S06.30"/>
              <display value="Unspecified focal traumatic brain injury"/>
            </coding>
          </diagnosisCodeableConcept>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
              <code value="principal"/>
            </coding>
          </type>
          <packageCode>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
              <code value="400"/>
              <display value="Head trauma - concussion"/>
            </coding>
          </packageCode>
        </diagnosis>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>🔗 
            <reference value="Coverage/coverage1001"/>
          </coverage>
        </insurance>
        <item>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
            <valueString value="Imaging"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum">
            <valueIdentifier>
              <value value="GFEBillingProviderLineItemCtrlNum-0001"/>
            </valueIdentifier>
          </extension>
          <sequence value="1"/>
          <productOrService>
            <coding>
              <system value="http://www.ama-assn.org/go/cpt"/>
              <code value="70551"/>
              <display
                       value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
            </coding>
          </productOrService>
          <modifier>
            <coding>
              <system value="http://www.ama-assn.org/go/cpt"/>
              <code value="70551"/>
              <display
                       value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
            </coding>
          </modifier>
          <servicedDate value="2021-10-31"/>
          <locationCodeableConcept>
            <coding>
              <system
                      value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
              <code value="21"/>
              <display value="Inpatient Hospital"/>
            </coding>
          </locationCodeableConcept>
          <quantity>
            <value value="1"/>
          </quantity>
          <unitPrice>
            <value value="200"/>
            <currency value="USD"/>
          </unitPrice>
          <net>
            <value value="200"/>
            <currency value="USD"/>
          </net>
        </item>
        <total>
          <value value="200"/>
          <currency value="USD"/>
        </total>
      </Claim>
    </resource>
  </entry>
  <entry id="Submitter-Practitioner-1">
    <fullUrl
             value="http://example.org/fhir/Practitioner/Submitter-Practitioner-1"/>
    <resource>
      <Practitioner>
        <id value="Submitter-Practitioner-1"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Practitioner</b><a name="Submitter-Practitioner-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 Practitioner &quot;Submitter-Practitioner-1&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-practitioner.html">PCT Practitioner</a></p></div><p><b>identifier</b>: National provider identifier: <a href="http://terminology.hl7.org/5.3.0/NamingSystem-npi.html">#</a>6456789016, Electronic Transmitter Identification Number: ETIN-20020001</p><p><b>active</b>: true</p><p><b>name</b>: Nora Ologist</p><p><b>telecom</b>: ph: 860-547-3301(WORK), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="NPI"/>
            </coding>
          </type>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="6456789016"/>
        </identifier>
        <identifier>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
              <code value="ETIN"/>
            </coding>
          </type>
          <system value="http://example.com/us-etin"/>
          <value value="ETIN-20020001"/>
        </identifier>
        <active value="true"/>
        <name>
          <text value="Nora Ologist"/>
          <family value="Ologist"/>
          <given value="Nora"/>
        </name>
        <telecom>
          <system value="phone"/>
          <value value="860-547-3301"/>
          <use value="work"/>
        </telecom>
        <telecom>
          <system value="email"/>
          <value value="csender@GFEServiceHelp.com"/>
          <use value="work"/>
        </telecom>
      </Practitioner>
    </resource>
  </entry>
  <entry id="org1001">
    <fullUrl value="http://example.org/fhir/Organization/org1001"/>
    <resource>
      <Organization>
        <id value="org1001"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
        </meta>
        <text>
          <status value="generated"/>
          <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: 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>
        </text>
        <identifier>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
              <code value="ETIN"/>
            </coding>
          </type>
          <value value="ETIN-3200002"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/organization-type"/>
            <code value="pay"/>
            <display value="Payer"/>
          </coding>
        </type>
        <name value="Umbrella Insurance Company"/>
        <telecom>
          <system value="phone"/>
          <value value="860-547-5001"/>
          <use value="work"/>
        </telecom>
        <address>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
            <valueCoding>
              <system value="urn:iso:std:iso:3166:-2"/>
              <code value="US-CT"/>
            </valueCoding>
          </extension>
          <line value="680 Asylum Street"/>
          <city value="Hartford"/>
          <state value="CT"/>
          <postalCode value="06155"/>
          <country value="US"/>
        </address>
      </Organization>
    </resource>
  </entry>
  <entry id="patient1001">
    <fullUrl value="http://example.org/fhir/Patient/patient1001"/>
    <resource>
      <Patient>
        <id value="patient1001"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
        </meta>
        <text>
          <status value="generated"/>
          <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: 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>
        </text>
        <identifier>
          <system value="http://example.com/identifiers/patient"/>
          <value value="1001"/>
        </identifier>
        <name>
          <text value="Eve Betterhalf"/>
          <family value="Betterhalf"/>
          <given value="Eve"/>
        </name>
        <telecom>
          <system value="phone"/>
          <value value="781-949-4949"/>
          <use value="mobile"/>
        </telecom>
        <gender value="female"/>
        <birthDate value="1955-07-23"/>
        <address>
          <text value="222 Burlington Road, Bedford MA 01730"/>
        </address>
        <maritalStatus>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
            <code value="U"/>
            <display value="unmarried"/>
          </coding>
        </maritalStatus>
        <communication>
          <language>
            <coding>
              <system value="urn:ietf:bcp:47"/>
              <code value="en-US"/>
              <display value="English (United States)"/>
            </coding>
          </language>
          <preferred value="true"/>
        </communication>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
    <resource>
      <Coverage>
        <id value="coverage1001"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="active"/>
        <subscriberId value="PFP123450000"/>
        <beneficiary>🔗 
          <reference value="Patient/patient1001"/>
        </beneficiary>
        <relationship>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
            <code value="self"/>
            <display value="Self"/>
          </coding>
        </relationship>
        <period>
          <start value="2021-01-01"/>
          <end value="2022-01-01"/>
        </period>
        <payor>🔗 
          <reference value="Organization/org1001"/>
        </payor>
        <class>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
              <code value="plan"/>
              <display value="Plan"/>
            </coding>
          </type>
          <value value="Premim Family Plus"/>
          <name value="Premim Family Plus Plan"/>
        </class>
        <costToBeneficiary>
          <type>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
              <code value="copaypct"/>
              <display value="Copay Percentage"/>
            </coding>
          </type>
          <valueQuantity>
            <value value="20"/>
          </valueQuantity>
        </costToBeneficiary>
      </Coverage>
    </resource>
  </entry>
</Bundle>