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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| 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
| Focal | Coverage |
| true | Coverage/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
Value Currency 200 USD Adjudications
Extension Category Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement)
| Extension | Category |
| 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
Value Currency 200 USD
| Extension | Text |
| 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
Extension Type Allowed[x] Used[x] Allowed (PCT Financial Type Code System#allowed) US$1.00 (USD) US$1.00 (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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