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-GFE-Bundle-Prof-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-23473847"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-09T11:01:00+05:00"/>
<entry id="PCT-GFE-Professional-MRI">
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Professional-MRI"/>
<resource>
<Claim>
<id value="PCT-GFE-Professional-MRI"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"/>
</meta>
<text>
<status value="extensions"/>
<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: GFEBillingProviderLineItemCtrlNum-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>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter">
<valueReference>
<reference value="Practitioner/Submitter-Practitioner-1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
<valueString value="EEMM1022"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
<extension url="linkingIdentifier">
<valueString value="223452-2342-2435-008001"/>
</extension>
<extension url="plannedPeriodOfService">
<valueDate value="2021-10-31"/>
</extension>
</extension>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PLAC"/>
<display value="Placer Identifier"/>
</coding>
</type>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<value value="GFEProviderAssignedID0002"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
<display value="Professional"/>
</coding>
</type>
<use value="predetermination"/>
<patient>
<reference value="Patient/patient1001"/>
</patient>
<created value="2021-10-05"/>
<insurer>
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
<valueCodeableConcept>
<coding>
<system value="http://nucc.org/provider-taxonomy"/>
<code value="2085D0003X"/>
<display
value="Diagnostic Neuroimaging (Radiology) Physician"/>
</coding>
</valueCodeableConcept>
</extension>
<reference value="Practitioner/Submitter-Practitioner-1"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
</payee>
<referral>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
<valueString value="REF12022002-122"/>
</extension>
<display value="Referral Number"/>
</referral>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
<valueString value="Imaging"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum">
<valueIdentifier>
<value value="GFEBillingProviderLineItemCtrlNum-0001"/>
</valueIdentifier>
</extension>
<sequence value="1"/>
<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="2021-10-31"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
<display value="Inpatient Hospital"/>
</coding>
</locationCodeableConcept>
<quantity>
<value value="1"/>
</quantity>
<unitPrice>
<value value="200"/>
</unitPrice>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
</item>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry id="Submitter-Practitioner-1">
<fullUrl
value="http://example.org/fhir/Practitioner/Submitter-Practitioner-1"/>
<resource>
<Practitioner>
<id value="Submitter-Practitioner-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="6456789016"/>
</identifier>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<system value="http://example.com/us-etin"/>
<value value="ETIN-20020001"/>
</identifier>
<active value="true"/>
<name>
<text value="Nora Ologist"/>
<family value="Ologist"/>
<given value="Nora"/>
</name>
<telecom>
<system value="phone"/>
<value value="860-547-3301"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="csender@GFEServiceHelp.com"/>
<use value="work"/>
</telecom>
</Practitioner>
</resource>
</entry>
<entry id="org1001">
<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>
<entry id="patient1001">
<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>
</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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