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 ExplanationOfBenefit: PCT-AEOB-1

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit

Resource ExplanationOfBenefit "PCT-AEOB-1"

Profile: PCT Advanced EOB

GFE Reference: Bundle/PCT-GFE-Bundle-Inst-1

Service Description: Example service

In Network Provider Options Link: http://example.com/out-of-network.html

identifier: Unique Claim ID: ?ngen-9?

status: active

type: Institutional (Claim Type Codes#institutional)

use: predetermination

patient: Patient/patient1001 " BETTERHALF"

created: 2021-10-12

insurer: Organization/org1001 "Umbrella Insurance Company"

provider: Organization/org1002 "Boston Radiology Center"

priority: Normal (Process Priority Codes#normal)

claim: id: 59688475-2324-3242-23473847

outcome: complete

Insurances

-FocalCoverage
*trueCoverage/coverage1001

item

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: 2022-01-01

Nets

-ValueCurrency
*200USD

Adjudications

-ExtensionCategory
*Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement)

Adjudications

-ExtensionCategory
*Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement)
* Submitted Amount (Adjudication Value Codes#submitted)
* Member Liability (PCT Adjudication Category CodeSystem#memberliability)

total

category: Submitted Amount (Adjudication Value Codes#submitted)

Amounts

-ValueCurrency
*200USD

ProcessNotes

-ExtensionText
*processNote disclaimer text

benefitPeriod: 2022-01-01 --> 2023-01-01

benefitBalance

category: Medical Care (X12 Service Type Codes#1)

unit: Individual (Unit Type Codes#individual)

term: Annual (Benefit Term Codes#annual)

Financials

-ExtensionTypeAllowed[x]Used[x]
*Allowed (PCT Financial Type Code System#allowed)US$1.00 (USD)US$1.00 (USD)