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

Example Claim: PCT-GFE-Institutional-1

Page standards status: Informative

Generated Narrative: Claim

Resource Claim "PCT-GFE-Institutional-1"

Profile: PCT Good Faith Estimate Institutional

GFESubmitter: Organization/Submitter-Org-1 "GFE Service Help INC."

ProviderEventMethodology: EEMM1021

GFEDisclaimer: For estimation purposes only

GFEServiceLinkingInfo

url

linkingIdentifier

value: 223452-2342-2435-008001

url

plannedPeriodOfService

value: 2021-10-31

identifier: Placer Identifier: GFEProviderAssignedID0001

status: active

type: Institutional (Claim Type Codes#institutional)

use: predetermination

patient: Patient/patient1001 " BETTERHALF"

created: 2021-10-05

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: Organization/Submitter-Org-1 "GFE Service Help INC."

priority: Normal (Process Priority Codes#normal)

Payees

-Type
*Provider (Payee Type Codes#provider)

referral: : Referral Number

SupportingInfos

-SequenceCategoryCode
*1Type of Bill (PCT GFE Supporting Info Type Code System#typeofbill)Hospital Inpatient (Part A) (AHA NUBC Type Of Bill Codes#011X)

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30)Principal Diagnosis (Example Diagnosis Type Codes#principal)Head trauma - concussion (Example Diagnosis Related Group Codes#400)

Insurances

-SequenceFocalCoverage
*1trueCoverage/coverage1001

item

Service Description: Imaging

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: 2021-10-31

quantity: 1

Nets

-ValueCurrency
*200USD

Totals

-ValueCurrency
*200USD