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

: PCT-GFE-Institutional-1 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Claim ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "PCT-GFE-Institutional-1"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"PCT-GFE-Institutional-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 Claim &quot;PCT-GFE-Institutional-1&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-institutional.html\">PCT Good Faith Estimate Institutional</a></p></div><p><b>GFESubmitter</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization/Submitter-Org-1</a> &quot;GFE Service Help INC.&quot;</p><p><b>ProviderEventMethodology</b>: EEMM1021</p><p><b>GFEDisclaimer</b>: For estimation purposes only</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: GFEProviderAssignedID0001</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.html\">Patient/patient1001</a> &quot; BETTERHALF&quot;</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> &quot;Umbrella Insurance Company&quot;</p><p><b>provider</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization/Submitter-Org-1</a> &quot;GFE Service Help INC.&quot;</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>SupportingInfos</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td>*</td><td>1</td><td>Type of Bill <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PCTSupportingInfoType.html\">PCT GFE Supporting Info Type Code System</a>#typeofbill)</span></td><td>Hospital Inpatient (Part A) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-AHANUBCTypeOfBill.html\">AHA NUBC Type Of Bill Codes</a>#011X)</span></td></tr></table><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.html\">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</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>: 2021-10-31</p><p><b>quantity</b>: 1</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></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>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Organization/Submitter-Org-1" ]     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology"^^xsd:anyURI ] ;
fhir:value [ fhir:v "EEMM1021" ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer"^^xsd:anyURI ] ;
fhir:value [ fhir:v "For estimation purposes only" ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "linkingIdentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "223452-2342-2435-008001" ]     ] [
fhir:url [ fhir:v "plannedPeriodOfService"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2021-10-31"^^xsd:date ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"^^xsd:anyURI ]
  ] ) ; # 
  fhir:identifier ( [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ] ;
fhir:code [ fhir:v "PLAC" ] ;
fhir:display [ fhir:v "Placer Identifier" ]       ] )     ] ;
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ] ;
fhir:value [ fhir:v "GFEProviderAssignedID0001" ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "institutional" ] ;
fhir:display [ fhir:v "Institutional" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "predetermination"] ; # 
  fhir:patient [
fhir:reference [ fhir:v "Patient/patient1001" ]
  ] ; # 
  fhir:created [ fhir:v "2021-10-05"^^xsd:date] ; # 
  fhir:insurer [
fhir:reference [ fhir:v "Organization/org1001" ]
  ] ; # 
  fhir:provider [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://nucc.org/provider-taxonomy"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2085D0003X" ] ;
fhir:display [ fhir:v "Diagnostic Neuroimaging (Radiology) Physician" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]     ] ) ;
fhir:reference [ fhir:v "Organization/Submitter-Org-1" ]
  ] ; # 
  fhir:priority [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "normal" ]     ] )
  ] ; # 
  fhir:payee [
fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ]       ] )     ]
  ] ; # 
  fhir:referral [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "REF12022002-121" ]     ] ) ;
fhir:display [ fhir:v "Referral Number" ]
  ] ; # 
  fhir:supportingInfo ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType"^^xsd:anyURI ] ;
fhir:code [ fhir:v "typeofbill" ]       ] )     ] ;
fhir:code [
      ( fhir:coding [
fhir:system [ fhir:v "https://www.nubc.org/CodeSystem/TypeOfBill"^^xsd:anyURI ] ;
fhir:code [ fhir:v "011X" ] ;
fhir:display [ fhir:v "Hospital Inpatient (Part A)" ]       ] )     ]
  ] ) ; # 
  fhir:diagnosis ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "S06.30" ] ;
fhir:display [ fhir:v "Unspecified focal traumatic brain injury" ]       ] )     ] ;
    ( fhir:type [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "principal" ]       ] )     ] ) ;
fhir:packageCode [
      ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"^^xsd:anyURI ] ;
fhir:code [ fhir:v "400" ] ;
fhir:display [ fhir:v "Head trauma - concussion" ]       ] )     ]
  ] ) ; # 
  fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/coverage1001" ]     ]
  ] ) ; # 
  fhir:item ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Imaging" ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:revenue [
      ( fhir:coding [
fhir:system [ fhir:v "https://www.nubc.org/CodeSystem/RevenueCodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "0611" ] ;
fhir:display [ fhir:v "Magnetic Resonance Technology (MRT) - Brain/brain stem" ]       ] )     ] ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ;
fhir:code [ fhir:v "70551" ] ;
fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem)" ]       ] )     ] ;
    ( fhir:modifier [
      ( fhir:coding [
fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ;
fhir:code [ fhir:v "70551" ] ;
fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem)" ]       ] )     ] ) ;
fhir:serviced [ fhir:v "2021-10-31"^^xsd:date ] ;
fhir:quantity [
fhir:value [ fhir:v "1"^^xsd:decimal ]     ] ;
fhir:net [
fhir:value [ fhir:v "200"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]     ]
  ] ) ; # 
  fhir:total [
fhir:value [ fhir:v "200"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ]
  ] . #