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-AEOB-1 - JSON Representation

Page standards status: Informative

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "PCT-AEOB-1",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
    ]
  },
  "text" : {
    "status" : "extensions",
    "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 &quot;PCT-AEOB-1&quot; </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:\u00a0?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.html\">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Organization/org1002</a> &quot;Boston Radiology Center&quot;</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:\u00a059688475-2324-3242-23473847</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.html\">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 --&gt; 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>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
      "valueReference" : {
        🔗 "reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
      }
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
      "valueString" : "Example service"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
      "valueUrl" : "http://example.com/out-of-network.html"
    }
  ],
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
            "code" : "uc",
            "display" : "Unique Claim ID"
          }
        ]
      }
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional",
        "display" : "Institutional"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    🔗 "reference" : "Patient/patient1001"
  },
  "created" : "2021-10-12",
  "insurer" : {
    🔗 "reference" : "Organization/org1001"
  },
  "provider" : {
    🔗 "reference" : "Organization/org1002"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "claim" : {
    "identifier" : {
      "system" : "http://example.com/identifiers/bundle",
      "value" : "59688475-2324-3242-23473847"
    }
  },
  "outcome" : "complete",
  "insurance" : [
    {
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/coverage1001"
      }
    }
  ],
  "item" : [
    {
      "sequence" : 1,
      "revenue" : {
        "coding" : [
          {
            "system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
            "code" : "0611",
            "display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem"
          }
        ]
      },
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.ama-assn.org/go/cpt",
            "code" : "70551",
            "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
          }
        ]
      },
      "modifier" : [
        {
          "coding" : [
            {
              "system" : "http://www.ama-assn.org/go/cpt",
              "code" : "70551",
              "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
            }
          ]
        }
      ],
      "servicedDate" : "2022-01-01",
      "net" : {
        "value" : 200,
        "currency" : "USD"
      },
      "adjudication" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
                    "code" : "concurrent-review",
                    "display" : "Concurrent Review"
                  }
                ]
              }
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "medicalmanagement",
                "display" : "Medical Management"
              }
            ]
          }
        }
      ]
    }
  ],
  "adjudication" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
                "code" : "concurrent-review",
                "display" : "Concurrent Review"
              }
            ]
          }
        }
      ],
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
            "code" : "medicalmanagement",
            "display" : "Medical Management"
          }
        ]
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "code" : "submitted",
            "display" : "Submitted Amount"
          }
        ]
      }
    },
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
            "code" : "memberliability",
            "display" : "Member Liability"
          }
        ]
      }
    }
  ],
  "total" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "code" : "submitted",
            "display" : "Submitted Amount"
          }
        ]
      },
      "amount" : {
        "value" : 200,
        "currency" : "USD"
      }
    }
  ],
  "processNote" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
                "code" : "disclaimer",
                "display" : "Disclaimer"
              }
            ]
          }
        }
      ],
      "text" : "processNote disclaimer text"
    }
  ],
  "benefitPeriod" : {
    "start" : "2022-01-01",
    "end" : "2023-01-01"
  },
  "benefitBalance" : [
    {
      "category" : {
        "coding" : [
          {
            "system" : "https://x12.org/codes/service-type-codes",
            "code" : "1",
            "display" : "Medical Care"
          }
        ]
      },
      "unit" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
            "code" : "individual"
          }
        ]
      },
      "term" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
            "code" : "annual"
          }
        ]
      },
      "financial" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
              "valueMoney" : {
                "value" : 0,
                "currency" : "USD"
              }
            }
          ],
          "type" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
                "code" : "allowed"
              }
            ]
          },
          "allowedMoney" : {
            "value" : 1,
            "currency" : "USD"
          },
          "usedMoney" : {
            "value" : 1,
            "currency" : "USD"
          }
        }
      ]
    }
  ]
}