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 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

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

Patient Cost Transparency Implementation Guide Capability Statement

Capability statement for the Da Vinci Patient Cost Transparency Implementation Guide

Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide.

Submit a GFE resource for the creation of an AEOB

This operation is used by an entity to submit one or multiple GFEs as a Bundle containing the GFE(s) and other referenced resources for processing. The only input parameter is the single Bundle resource with one or multiple GFE(s) - each of which is based on the Claim resource (along with other referenced resources). The only output is a url for subsequent polling per async pattern. If after polling the response is complete, then the result will either be a single Bundle with the AEOB - which is based on the ExplanationOfBenefit resource, (and other referenced resources) or an OperationOutcome resource indicating the AEOB will be sent directly to the patient and not to the provider.

Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

aeob-date-of-service

Select planned date of service

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

PCT AEOB Adjudication Error

OperationOutcome returned from the gfeSubmit operation when there are adjudication errors during AEOB processing

PCT AEOB Bundle

PCT AEOB Bundle that contains necessary resources for an AEOBs. Organizations for both the payer and provider SHALL be included.

PCT AEOB Complete

OperationOutcome returned from the gfeSubmit operation when the AEOB process is complete but no AEOB will be returned to the submitter (i.e. it was sent only to the patient)

PCT Advanced EOB

The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.

PCT Coverage

PCT Coverage is a profile for capturing data that reflect a payer’s coverage that was effective as of the proposed date of service or the date of admission of the GFE.

PCT GFE Bundle

PCT GFE Bundle that contains necessary resources as a GFE Submission for obtaining an AEOB. Organizations for both the provider and payer SHALL be included. The scope of this guide does not include coordination of benefits or more than one coverage. This does not serve as a replacement for eligibility, prior authorization or other financial and administrative use cases.

PCT GFE Validation Error

OperationOutcome returned from the gfeSubmit operation when the GFE Bundle fails FHIR validation

PCT Good Faith Estimate Institutional

PCT Good Faith Estimate Institutional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for an institutional GFE submission.

PCT Good Faith Estimate Professional

PCT Good Faith Estimate Professional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for a professional GFE submission.

PCT Organization

The PCT Organization profile builds upon the US Core Organization profile. It is used to convey a payer, provider, payee, or service facility organization.

PCT Practitioner

The PCT Practitioner profile builds upon the US Core Practitioner profile. It is used to convey information about the practitioner who will be providing services to the patient as described on the GFE.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

Benefit Remaining

The quantity of the benefit remaining to date.

CountrySubdivisionCode

This extension is used to provide the Country Subdivision Code - from Part 2 of ISO 3166.

GFE Reference

This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB.

GFEBillingProviderLineItemCtrlNum

This extension is used by the provider to assign a unique identifier to this item. The intent of this element is to allow the provider to assign something other than ‘line number’ for their purposes (e.g. tracking and troubleshooting).

GFEConsentForBalanceBilling

If the provider has received a written consent form indicating a patient has agreed to waive their protections and pay up to the full cost for the out-of-network item or service, this will be “true”. If the provider has not received written consent, this will be “false”. This is an attestation only. The billing provider is legally required to maintain the written notice and consent form.

GFEDisclaimer

Disclaimers the patient should be made aware of regarding the providers estimate

GFEServiceLinkingInfo

This extension is used to provide the GFE Service Linking Information. This allows implementers to have the same identifier on multiple GFEs that are part of one period of care’s services. This would be needed for some of the workflow options that businesses may decide to use.

GFESubmitter

This extension is used to indicate the scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB. All submitters (Practitioners and Organizations) must have an ETIN.

In Network Provider Options Link

This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services.

PCTEndpoint

This extension is used to provide an endpoint.

ProcessNote Class

This extension is used to indicate a the class of AEOB Claim process notes

ProviderEventMethodology

This extension is used for indicating the method a provider used to group services, and those providing such services, beyond what may be indicated through DRGs that the payer or patient may find helpful (e.g. grouping services by a standardized episode of care definition). This is provider generated text and should not be modified by the payer.

ProviderTaxonomy

This extension is used to indicate the taxonomy code of the provider.

ReferralNumber

This extension is used to provide the Referral Number.

Service Description

This extension is used to communicate a plain language description of the procedure, product, or service.

Subject To Medical Management

This extension is used to provide a reason to explain how the estimate may change subject to medical management.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Claim Medical Product or Service Value Set

CPT - HCPCS - HIPPS codes to report medical procedures and services under public and private health insurance programs

ICD-10 Procedure Codes

Procedure Codes from https://www.cms.gov/Medicare/Coding/ICD10

NUBC Point Of Origin

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially.

There are no gaps because all used and unused codes are identified. This value set consists of the following:

  • FL 15 - Point of Origin for Admission or Visit for Non-newborn
  • FL 15 - Point of Origin for Admission or Visit for Newborn

These codes are used to convey the patient point of origin for an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here Statement of Understanding between AHA and HL7 can be found here. In particular see sections 4.1d and 4.2.

The UB-04 Manual has a 12-month subscription period from June 30 through July 1.

For frequently asked questions, see here here

NUBC Priority (Type) of Admission or Visit

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This value set consists of the following:

  • FL 14 - Priority (Type) of Admission or Visit

These codes are used to convey the priority of an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here

Statement of Understanding between AHA and HL7 can be found here. In particular see sections 4.1d and 4.2.

The UB-04 Manual has a 12-month subscription period from June 30 through July 1.

For frequently asked questions, see here here

This Code system is referenced in the content logical definition of the following value sets:

This CodeSystem is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

This code system https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit defines many codes, but they are not represented here

PCT AEOB Process Note Types

Indicates the type of .processNote for AEOB.

PCT Adjudication Value Set

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

PCT Adjustment Reason

Codes indicating reasons why a claim or line item is adjusted.

PCT Advance Explanation of Benefit Type Value Set

Codes to specify the type of AEOB

PCT CMS HCPCS and AMA CPT Procedure Surgical Codes

Combination of CMS HCPCS and AMA CPT codes to specify the type of surgical procedure

PCT Care Team Role Value Set

Codes to specify the the functional roles of the care team members.

PCT Diagnosis Type Value Set

Codes to specify the type of diagnosis

PCT Financial Type Value Set

Financial Type codes for benefitBalance.financial.type.

PCT GFE CMS Place of Service Value Set

CMS Place of Service codes

PCT GFE Frequency Code Value Set

These codes in this value set are derived from the NUBC Uniform Billing (UB-04) Type of Bill (TOB) codes. The fourth digit of the TOB code defines the frequency of the bill for the institutional and electronic professional claim.

PCT GFE Item Adjudication Value Set

Value Set containing codes for the type of adjudication information provided.

PCT GFE Item CPT - HCPCS Value Set

CPT - HCPCS codes to report medical procedures and services under public and private health insurance programs

PCT GFE Item NDC Value Set

The FDA published list of NDC codes for finished drug products

PCT GFE NUBC Revenue Value Set

NUBC UB-04 Revenue codes

PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set

NUBC Uniform Billing (UB-04) codes to indicate the specific Type of Bill (TOB), e.g., hospital inpatient, outpatient, replacements, voids, etc. The first digit is a leading zero*. The fourth digit defines the frequency of the bill for the institutional and electronic professional claim.

PCT ICD-10 Diagnostic Codes

ICD-10 Codes to specify the type of diagnosis

PCT Organization Contact Purpose Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes for the classification of organization contact purposes

PCT Organization Identifier Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of identifiers for organizations to indicate usage for a specific purpose

PCT Organization Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of entity involved in the PCT GFE process

PCT Payer Benefit Payment Status

Indicates the in network or out of network payment status of the claim or line item.

PCT Payer Provider Network Status

Indicates the Provider network status with the Payer as of the effective date of service or admission.

PCT Procedure Type Value Set

Codes to specify the type of procedure

PCT Subject-To-Medical-Management Reason Value Set

Codes for the classification of subject-to-medical-management reasons

PCT Supporting Info Type Value Set

Codes to specify the type of the supplied supporting information

PCT benefitBalance.category codes

Category codes for PCT benefitBalance.category from X12 service type.

US Claim DRG Codes

US Claim Diagnosis Related Group Codes. All codes from MS-DRGs - AP-DRGs - APR-DRGs

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

PCT AEOB Process Note Code System

Defining codes for process notes. This is for trial use.

PCT Adjudication Category CodeSystem

Codes indicating the type of adjudication information provided.

PCT Adjudication Code System

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

PCT Care Team Role

PCT code system for defining the functional roles of the care team members.

PCT Diagnosis Type

Defining codes for the classification of diagnosis types

PCT Financial Type Code System

Financial Type codes for benefitBalance.financial.type.

PCT GFE Frequency Code System

These codes are derived from the NUBC Uniform Billing (UB-04) Type of Bill (TOB) codes. The fourth digit of the TOB code defines the frequency of the bill for the institutional and electronic professional claim.

PCT GFE Supporting Info Type Code System

Defining codes for the classification of the supplied supporting information

PCT Identifier Type

Defining codes for types of identifiers

PCT Network Status

Defining codes for network status. This is for trial use.

PCT Organization Contact Purpose Type Code System

Organization Contact Purpose Type Code System

PCT Organization Identifier Type Code System

Identifier Type codes for defining the type of identifier payers and providers assign to organizations

PCT Procedure Type

Defining codes for the classification of procedure types

PCT Subject-To-Medical-Management Reason Code System

Defining codes for the classification of subject-to-medical-management reason types

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

PCT-AEOB-1

An instance of the PCTAdvancedEOB Profile

PCT-AEOB-Adjudication-Error-Example-1

PCT AEOB Adjudication Error Example 1

PCT-AEOB-Bundle-1

PCT AEOB Bundle Example 1

PCT-AEOB-Complete-Example-1

PCT AEOB Complete Example 1

PCT-GFE-Bundle-Inst-1

PCT GFE Bundle Institutional Example 1

PCT-GFE-Bundle-Prof-1

PCT GFE Bundle Professional Example 1

PCT-GFE-Institutional-1

PCT Institutional GFE Example 1

PCT-GFE-Institutional-MRI

PCT Institutional GFE for MRI

PCT-GFE-Professional-MRI

PCT Professional GFE Example 1

PCT-GFE-Validation-Error-Example-1

PCT GFE Validation Error Example 1

Submitter-Org-1

Institutional GFE Submitter 1

Submitter-Practitioner-1

Professional GFE Submitter 1

contract1001

An instance of Contract

coverage1001

An instance of PCTCoverage

endpoint001

An instance of Endpoint

org1001

An instance of PCTOrganization as a payer

org1002

An instance of PCTOrganization as a healthcare provider

patient1001

An instance of Patient

prac001

An instance of PCTPractitioner

prac002

An instance of PCTPractitioner