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 
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PCT-AEOB-1"
Profile: PCT Advanced EOB
GFE Reference: Bundle/PCT-GFE-Bundle-Inst-1
Service Description: Example service
identifier: Unique Claim ID: ?ngen-9?
status: active
type: Institutional (Claim Type Codes#institutional)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
created: 2021-10-12
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: Organization/org1002 "Boston Radiology Center"
priority: Normal (Process Priority Codes#normal)
claim:
outcome: complete
| - | Focal | Coverage |
| * | true | Coverage/coverage1001 |
item
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: 2022-01-01
Nets
- Value Currency * 200 USD Adjudications
- Extension Category * Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement)
| - | Extension | Category |
| * | Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement) | |
| * | Submitted Amount (Adjudication Value Codes#submitted) | |
| * | Member Liability (PCT Adjudication Category CodeSystem#memberliability) |
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency * 200 USD
| - | Extension | Text |
| * | processNote disclaimer text |
benefitPeriod: 2022-01-01 --> 2023-01-01
benefitBalance
category: Medical Care (service-type-codes#1)
unit: Individual (Unit Type Codes#individual)
term: Annual (Benefit Term Codes#annual)
Financials
- Type Allowed[x] Used[x] * Allowed (PCT Financial Type Code System#allowed) US$1.00 (USD) US$1.00 (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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