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 
@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-MRI"] ; #
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-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-Institutional-MRI" </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> "GFE Service Help INC."</p><p><b>ProviderEventMethodology</b>: EEMM1021</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008002</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2022-02-02</p></blockquote><p><b>identifier</b>: Placer Identifier: GFEProviderAssignedID0001MRI</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> " BETTERHALF"</p><p><b>created</b>: 2022-02-02</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> "Umbrella Insurance Company"</p><p><b>provider</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization/Submitter-Org-1</a> "GFE Service Help INC."</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>example-bill-type <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>#example-bill-type)</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>serviced</b>: 2022-02-02</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>266</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>266</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:extension [
fhir:url [ fhir:v "linkingIdentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "223452-2342-2435-008002" ] ] [
fhir:url [ fhir:v "plannedPeriodOfService"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2022-02-02"^^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:value [ fhir:v "GFEProviderAssignedID0001MRI" ]
] ) ; #
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 "2022-02-02"^^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: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 "REF12022002-122" ] ] ) ;
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 "example-bill-type" ] ] ) ]
] ) ; #
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:serviced [ fhir:v "2022-02-02"^^xsd:date ] ;
fhir:quantity [
fhir:value [ fhir:v "1"^^xsd:decimal ] ] ;
fhir:net [
fhir:value [ fhir:v "266"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ]
] ) ; #
fhir:total [
fhir:value [ fhir:v "266"^^xsd:decimal ] ;
fhir:currency [ fhir:v "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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