Patient Cost Transparency Implementation Guide
1.0.0 - STU 1 United States of America flag

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

Example Bundle: PCT-GFE-Bundle-Prof-1

Bundle PCT-GFE-Bundle-Prof-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI

Resource Claim:

Generated Narrative: Claim

Resource Claim "PCT-GFE-Professional-MRI"

Profile: PCT Good Faith Estimate Professional

Texts

-Div
*<div/>

GFESubmitter: See above (Practitioner/Submitter-Practitioner-1)

ProviderEventMethodology: EEMM1022

GFEServiceLinkingInfo

url

linkingIdentifier

value: 223452-2342-2435-008001

url

plannedPeriodOfService

value: 2021-10-31

identifier: Placer Identifier: GFEProviderAssignedID0002

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREDETERMINATION

patient: See above (Patient/patient1001)

created: 2021-10-05

insurer: See above (Organization/org1001)

provider: See above (Practitioner/Submitter-Practitioner-1)

priority: Normal (Process Priority Codes#normal)

Payees

-Type
*Provider (Claim Payee Type Codes#provider)

referral: : Referral Number

Diagnoses

-SequenceDiagnosis[x]Type
*1Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30)Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-SequenceFocalCoverage
*1trueSee above (Coverage/coverage1001)

item

Service Description: Imaging

GFEBillingProviderLineItemCtrlNum: id: GFEBillingProviderLineItemCtrlNum-0001

sequence: 1

productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem) (Current Procedural Terminology (CPT®)#70551)

modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem) (Current Procedural Terminology (CPT®)#70551)

serviced: 2021-10-31

location: Inpatient Hospital (CMS Place of Service Codes (POS)#21)

quantity: 1

UnitPrices

-Value
*200

Nets

-ValueCurrency
*200USD

Totals

-ValueCurrency
*200USD

Entry 2 - fullUrl = http://example.org/fhir/Practitioner/Submitter-Practitioner-1

Resource Practitioner:

Generated Narrative: Practitioner

Resource Practitioner "Submitter-Practitioner-1"

Profile: PCT Practitioner

Texts

-Div
*<div/>

identifier: National provider identifier: 6456789016, Electronic Transmitter Identification Number: ETIN-20020001

active: true

name: Nora Ologist

telecom: ph: 860-547-3301(WORK), csender@GFEServiceHelp.com

Entry 3 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

Generated Narrative: Organization

Resource Organization "org1001"

Profile: PCT Organization

Texts

-Div
*<div/>

identifier: Electronic Transmitter Identification Number: ETIN-3200002

active: true

type: Payer (Organization type#pay)

name: Umbrella Insurance Company

Contacts

-TelecomAddress
*ph: 860-547-5001(WORK)680 Asylum Street Hartford CT 06155 US

Entry 4 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

Eve Betterhalf Female, DoB: 1955-07-23 ( id: 1001)

Entry 5 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

Generated Narrative: Coverage

Resource Coverage "coverage1001"

Profile: PCT Coverage

Texts

-Div
*<div/>

status: ACTIVE

subscriberId: id: PFP123450000

beneficiary: See above (Patient/patient1001)

relationship: Self (SubscriberPolicyholder Relationship Codes#self)

period: 2021-01-01 --> 2022-01-01

Classes

-TypeValueName
*Plan (Coverage Class Codes#plan)id: Premim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage (Coverage Copay Type Codes#copaypct)20