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
| Page standards status: Informative |
Resource Claim "PCT-GFE-Professional-MRI"
Profile: PCT Good Faith Estimate Professional
GFESubmitter: Practitioner/Submitter-Practitioner-1 " OLOGIST"
ProviderEventMethodology: EEMM1022
GFEServiceLinkingInfo
url
linkingIdentifiervalue: 223452-2342-2435-008001
url
plannedPeriodOfServicevalue: 2021-10-31
identifier: Placer Identifier: GFEProviderAssignedID0002
status: active
type: Professional (Claim Type Codes#professional)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
created: 2021-10-05
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: Practitioner/Submitter-Practitioner-1 " OLOGIST"
priority: Normal (Process Priority Codes#normal)
| Type |
| Provider (Payee Type Codes#provider) |
referral: : Referral Number
| Sequence | Diagnosis[x] | Type | PackageCode |
| 1 | Unspecified 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) |
| Sequence | Focal | Coverage |
| 1 | true | Coverage/coverage1001 |
item
Service Description: Imaging
GFEBillingProviderLineItemCtrlNum: id: GFEBillingProviderLineItemCtrlNum-0001
sequence: 1
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
location: Inpatient Hospital (CMS Place of Service Codes (POS)#21)
quantity: 1
UnitPrices
Value Currency 200 USD Nets
Value Currency 200 USD
| Value | Currency |
| 200 | USD |
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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