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 
Resource Claim "PCT-GFE-Institutional-1"
GFESubmitter: Organization/Submitter-Org-1 "GFE Service Help INC."
ProviderEventMethodology: EEMM1021
GFEDisclaimer: For estimation purposes only
GFEServiceLinkingInfo
url
linkingIdentifiervalue: 223452-2342-2435-008001
url
plannedPeriodOfServicevalue: 2021-10-31
identifier: Placer Identifier: GFEProviderAssignedID0001
status: active
type: Institutional (Claim Type Codes#institutional)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
created: 2021-10-05
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: Organization/Submitter-Org-1 "GFE Service Help INC."
priority: Normal (Process Priority Codes#normal)
| - | Type |
| * | Provider (Claim Payee Type Codes#provider) |
referral: : Referral Number
| - | Sequence | Category | Code |
| * | 1 | Type of Bill (PCT GFE Supporting Info Type Code System#typeofbill) | Hospital Inpatient (Part A) (AHA NUBC Type Of Bill Codes#011X) |
| - | Sequence | Diagnosis[x] | Type | PackageCode |
| * | 1 | Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30) | Principal Diagnosis (Example Diagnosis Type Codes#principal) | Head trauma - concussion (Example Diagnosis Related Group Codes#400) |
| - | Sequence | Focal | Coverage |
| * | 1 | true | Coverage/coverage1001 |
item
Service Description: Imaging
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)
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
quantity: 1
Nets
- Value Currency * 200 USD
| - | Value | Currency |
| * | 200 | USD |
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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