Patient Cost Transparency Implementation Guide
1.0.0 - STU 1
Patient Cost Transparency Implementation Guide
1.0.0 - STU 1
This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v1.0.0: STU 1) based on FHIR 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 
{
"resourceType" : "Bundle",
"id" : "PCT-AEOB-Bundle-1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle"
]
},
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-1234567"
},
"type" : "collection",
"timestamp" : "2021-11-10T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Inst-Example-1",
"resource" : {
"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 "PCT-AEOB-1" </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>identifier</b>: Unique Claim ID: ?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/5.0.0/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\">See above (Patient/patient1001)</a></p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href=\"#Organization_org1001\">See above (Organization/org1001)</a></p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Organization/org1002</a> "Boston Radiology Center"</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>claim</b>: <span/></p><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href=\"#Coverage_coverage1001\">See above (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/5.0.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#0611)</span></p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>modifier</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/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>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>200</td><td>USD</td></tr></table><h3>Adjudications</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td>*</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>-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td>*</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>*</td><td> </td><td>Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></td></tr><tr><td>*</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/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td>*</td><td>200</td><td>USD</td></tr></table></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td>-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td>*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --> 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\"> (service-type-codes#1)</span></p><p><b>unit</b>: Individual <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/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/5.0.0/CodeSystem-benefit-term.html\">Benefit Term Codes</a>#annual)</span></p><h3>Financials</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><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"
}
],
"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" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
"valueUrl" : "http://example.com/out-of-network.html"
}
],
"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)"
}
]
},
"modifier" : [
{
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "70551",
"display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem)"
}
]
}
],
"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" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"code" : "allowed"
}
]
},
"allowedMoney" : {
"value" : 1,
"currency" : "USD"
},
"usedMoney" : {
"value" : 1,
"currency" : "USD"
}
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/patient1001",
"resource" : {
"resourceType" : "Patient",
"id" : "patient1001",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Patient</b><a name=\"patient1001\"> </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 Patient "patient1001" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"http://hl7.org/fhir/us/davinci-hrex/STU1/StructureDefinition-hrex-patient-demographics.html\">HRex Patient Demographics</a></p></div><p><b>identifier</b>: id:\u00a01001</p><p><b>name</b>: Eve Betterhalf</p><p><b>telecom</b>: ph: 781-949-4949(MOBILE)</p><p><b>gender</b>: female</p><p><b>birthDate</b>: 1955-07-23</p><p><b>address</b>: 222 Burlington Road, Bedford MA 01730</p><p><b>maritalStatus</b>: unmarried <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-v3-MaritalStatus.html\">MaritalStatus</a>#U)</span></p><h3>Communications</h3><table class=\"grid\"><tr><td>-</td><td><b>Language</b></td><td><b>Preferred</b></td></tr><tr><td>*</td><td>English (United States) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-v3-ietf3066.html\">Tags for the Identification of Languages</a>#en-US)</span></td><td>true</td></tr></table></div>"
},
"identifier" : [
{
"system" : "http://example.com/identifiers/patient",
"value" : "1001"
}
],
"name" : [
{
"text" : "Eve Betterhalf",
"family" : "Betterhalf",
"given" : [
"Eve"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "781-949-4949",
"use" : "mobile"
}
],
"gender" : "female",
"birthDate" : "1955-07-23",
"address" : [
{
"text" : "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code" : "U",
"display" : "unmarried"
}
]
},
"communication" : [
{
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en-US",
"display" : "English (United States)"
}
]
},
"preferred" : true
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/coverage1001",
"resource" : {
"resourceType" : "Coverage",
"id" : "coverage1001",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Coverage</b><a name=\"coverage1001\"> </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 Coverage "coverage1001" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-coverage.html\">PCT Coverage</a></p></div><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href=\"#Patient_patient1001\">See above (Patient/patient1001)</a></p><p><b>relationship</b>: Self <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-subscriber-relationship.html\">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href=\"#Organization_org1001\">See above (Organization/org1001)</a></p><h3>Classes</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td>*</td><td>Plan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>Copay Percentage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-coverage-copay-type.html\">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>"
},
"status" : "active",
"subscriberId" : "PFP123450000",
"beneficiary" : {
"reference" : "Patient/patient1001"
},
"relationship" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code" : "self",
"display" : "Self"
}
]
},
"period" : {
"start" : "2021-01-01",
"end" : "2022-01-01"
},
"payor" : [
{
"reference" : "Organization/org1001"
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "plan",
"display" : "Plan"
}
]
},
"value" : "Premim Family Plus",
"name" : "Premim Family Plus Plan"
}
],
"costToBeneficiary" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "copaypct",
"display" : "Copay Percentage"
}
]
},
"valueQuantity" : {
"value" : 20
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/org1001",
"resource" : {
"resourceType" : "Organization",
"id" : "org1001",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"org1001\"> </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 Organization "org1001" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-organization.html\">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number: ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-organization-type.html\">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US </p></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS",
"code" : "ETIN"
}
]
},
"value" : "ETIN-3200002"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "pay",
"display" : "Payer"
}
]
}
],
"name" : "Umbrella Insurance Company",
"telecom" : [
{
"system" : "phone",
"value" : "860-547-5001",
"use" : "work"
}
],
"address" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode",
"valueCoding" : {
"system" : "urn:iso:std:iso:3166:-2",
"code" : "US-CT"
}
}
],
"line" : [
"680 Asylum Street"
],
"city" : "Hartford",
"state" : "CT",
"postalCode" : "06155",
"country" : "US"
}
]
}
}
]
}
IG © 2023+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pct#1.0.0 based on FHIR 4.0.1. Generated 2023-03-30
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