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-GFE-Bundle-Prof-1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"
]
},
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-23473847"
},
"type" : "collection",
"timestamp" : "2021-11-09T11:01:00+05:00",
"entry" : [
{
"id" : "PCT-GFE-Professional-MRI",
"fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Professional-MRI",
"resource" : {
"resourceType" : "Claim",
"id" : "PCT-GFE-Professional-MRI",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"PCT-GFE-Professional-MRI\"> </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 Claim "PCT-GFE-Professional-MRI" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-professional.html\">PCT Good Faith Estimate Professional</a></p></div><p><b>GFESubmitter</b>: <a href=\"#Practitioner_Submitter-Practitioner-1\">See above (Practitioner/Submitter-Practitioner-1)</a></p><p><b>ProviderEventMethodology</b>: EEMM1022</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008001</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2021-10-31</p></blockquote><p><b>identifier</b>: Placer Identifier: GFEProviderAssignedID0002</p><p><b>status</b>: active</p><p><b>type</b>: Professional <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>#professional)</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>: 2021-10-05</p><p><b>insurer</b>: <a href=\"#Organization_org1001\">See above (Organization/org1001)</a></p><p><b>provider</b>: <a href=\"#Practitioner_Submitter-Practitioner-1\">See above (Practitioner/Submitter-Practitioner-1)</a></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><h3>Payees</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td></tr><tr><td>*</td><td>Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-payeetype.html\">Claim Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td>*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-ex-diagnosisrelatedgroup.html\">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</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>Service Description</b>: Imaging</p><p><b>GFEBillingProviderLineItemCtrlNum</b>: id:\u00a0GFEBillingProviderLineItemCtrlNum-0001</p><p><b>sequence</b>: 1</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>: 2021-10-31</p><p><b>location</b>: Inpatient Hospital <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td></tr><tr><td>*</td><td>200</td></tr></table><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></blockquote><h3>Totals</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></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter",
"valueReference" : {
"reference" : "Practitioner/Submitter-Practitioner-1"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
"valueString" : "EEMM1022"
},
{
"extension" : [
{
"url" : "linkingIdentifier",
"valueString" : "223452-2342-2435-008001"
},
{
"url" : "plannedPeriodOfService",
"valueDate" : "2021-10-31"
}
],
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
}
],
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "PLAC",
"display" : "Placer Identifier"
}
]
},
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"value" : "GFEProviderAssignedID0002"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional",
"display" : "Professional"
}
]
},
"use" : "predetermination",
"patient" : {
"reference" : "Patient/patient1001"
},
"created" : "2021-10-05",
"insurer" : {
"reference" : "Organization/org1001"
},
"provider" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nucc.org/provider-taxonomy",
"code" : "2085D0003X",
"display" : "Diagnostic Neuroimaging (Radiology) Physician"
}
]
}
}
],
"reference" : "Practitioner/Submitter-Practitioner-1"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
}
},
"referral" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber",
"valueString" : "REF12022002-122"
}
],
"display" : "Referral Number"
},
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "S06.30",
"display" : "Unspecified focal traumatic brain injury"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal"
}
]
}
],
"packageCode" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
"code" : "400",
"display" : "Head trauma - concussion"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/coverage1001"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString" : "Imaging"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum",
"valueIdentifier" : {
"value" : "GFEBillingProviderLineItemCtrlNum-0001"
}
}
],
"sequence" : 1,
"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" : "2021-10-31",
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21",
"display" : "Inpatient Hospital"
}
]
},
"quantity" : {
"value" : 1
},
"unitPrice" : {
"value" : 200
},
"net" : {
"value" : 200,
"currency" : "USD"
}
}
],
"total" : {
"value" : 200,
"currency" : "USD"
}
}
},
{
"id" : "Submitter-Practitioner-1",
"fullUrl" : "http://example.org/fhir/Practitioner/Submitter-Practitioner-1",
"resource" : {
"resourceType" : "Practitioner",
"id" : "Submitter-Practitioner-1",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Practitioner</b><a name=\"Submitter-Practitioner-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 Practitioner "Submitter-Practitioner-1" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-practitioner.html\">PCT Practitioner</a></p></div><p><b>identifier</b>: National provider identifier: 6456789016, Electronic Transmitter Identification Number: ETIN-20020001</p><p><b>active</b>: true</p><p><b>name</b>: Nora Ologist</p><p><b>telecom</b>: ph: 860-547-3301(WORK), <a href=\"mailto:csender@GFEServiceHelp.com\">csender@GFEServiceHelp.com</a></p></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "NPI"
}
]
},
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "6456789016"
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS",
"code" : "ETIN"
}
]
},
"system" : "http://example.com/us-etin",
"value" : "ETIN-20020001"
}
],
"active" : true,
"name" : [
{
"text" : "Nora Ologist",
"family" : "Ologist",
"given" : [
"Nora"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "860-547-3301",
"use" : "work"
},
{
"system" : "email",
"value" : "csender@GFEServiceHelp.com",
"use" : "work"
}
]
}
},
{
"id" : "org1001",
"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"
}
]
}
},
{
"id" : "patient1001",
"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
}
}
]
}
}
]
}
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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