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 
<Bundle xmlns="http://hl7.org/fhir">
<id value="PCT-AEOB-Bundle-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-1234567"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-10T11:01:00+05:00"/>
<entry>
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Inst-Example-1"/>
<resource>
<ExplanationOfBenefit>
<id value="PCT-AEOB-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference">
<valueReference>
<reference value="Bundle/PCT-GFE-Bundle-Inst-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
<valueString value="Example service"/>
</extension>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType"/>
<code value="uc"/>
<display value="Unique Claim ID"/>
</coding>
</type>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
<display value="Institutional"/>
</coding>
</type>
<use value="predetermination"/>
<patient>
<reference value="Patient/patient1001"/>
</patient>
<created value="2021-10-12"/>
<insurer>
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink">
<valueUrl value="http://example.com/out-of-network.html"/>
</extension>
<reference value="Organization/org1002"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<claim>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-23473847"/>
</identifier>
</claim>
<outcome value="complete"/>
<insurance>
<focal value="true"/>
<coverage>
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<revenue>
<coding>
<system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
<code value="0611"/>
<display
value="Magnetic Resonance Technology (MRT) - Brain/brain stem"/>
</coding>
</revenue>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="70551"/>
<display
value="Magnetic resonance (eg, proton) imaging, brain (including brain stem)"/>
</coding>
</productOrService>
<modifier>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="70551"/>
<display
value="Magnetic resonance (eg, proton) imaging, brain (including brain stem)"/>
</coding>
</modifier>
<servicedDate value="2022-01-01"/>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"/>
<code value="concurrent-review"/>
<display value="Concurrent Review"/>
</coding>
</valueCodeableConcept>
</extension>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
<code value="medicalmanagement"/>
<display value="Medical Management"/>
</coding>
</category>
</adjudication>
</item>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"/>
<code value="concurrent-review"/>
<display value="Concurrent Review"/>
</coding>
</valueCodeableConcept>
</extension>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
<code value="medicalmanagement"/>
<display value="Medical Management"/>
</coding>
</category>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
</category>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
<code value="memberliability"/>
<display value="Member Liability"/>
</coding>
</category>
</adjudication>
<total>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
<display value="Submitted Amount"/>
</coding>
</category>
<amount>
<value value="200"/>
<currency value="USD"/>
</amount>
</total>
<processNote>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS"/>
<code value="disclaimer"/>
<display value="Disclaimer"/>
</coding>
</valueCodeableConcept>
</extension>
<text value="processNote disclaimer text"/>
</processNote>
<benefitPeriod>
<start value="2022-01-01"/>
<end value="2023-01-01"/>
</benefitPeriod>
<benefitBalance>
<category>
<coding>
<system value="https://x12.org/codes/service-type-codes"/>
<code value="1"/>
<display value="Medical Care"/>
</coding>
</category>
<unit>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
<code value="individual"/>
</coding>
</unit>
<term>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
<code value="annual"/>
</coding>
</term>
<financial>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"/>
<code value="allowed"/>
</coding>
</type>
<allowedMoney>
<value value="1"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="1"/>
<currency value="USD"/>
</usedMoney>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
</meta>
<text>
<status value="generated"/>
<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: 1001</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>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-CT"/>
</valueCoding>
</extension>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
</Bundle>
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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