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-AEOB-1 - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="PCT-AEOB-1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name="PCT-AEOB-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 ExplanationOfBenefit &quot;PCT-AEOB-1&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-aeob.html">PCT Advanced EOB</a></p></div><p><b>GFE Reference</b>: <a href="Bundle-PCT-GFE-Bundle-Inst-1.html">Bundle/PCT-GFE-Bundle-Inst-1</a></p><p><b>Service Description</b>: Example service</p><p><b>identifier</b>: Unique Claim ID: ?ngen-9?</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>: 2021-10-12</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-org1002.html">Organization/org1002</a> &quot;Boston Radiology Center&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><p><b>claim</b>: <span/></p><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></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>: 2022-01-01</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><h3>Adjudications</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td>*</td><td/><td>Medical Management <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTAdjudicationCategoryCS.html">PCT Adjudication Category CodeSystem</a>#medicalmanagement)</span></td></tr></table></blockquote><h3>Adjudications</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td>*</td><td/><td>Medical Management <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTAdjudicationCategoryCS.html">PCT Adjudication Category CodeSystem</a>#medicalmanagement)</span></td></tr><tr><td>*</td><td> </td><td>Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></td></tr><tr><td>*</td><td> </td><td>Member Liability <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTAdjudicationCategoryCS.html">PCT Adjudication Category CodeSystem</a>#memberliability)</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</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>ProcessNotes</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td>*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --&gt; 2023-01-01</p><blockquote><p><b>benefitBalance</b></p><p><b>category</b>: Medical Care <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (service-type-codes#1)</span></p><p><b>unit</b>: Individual <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-benefit-unit.html">Unit Type Codes</a>#individual)</span></p><p><b>term</b>: Annual <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.0.0/CodeSystem-benefit-term.html">Benefit Term Codes</a>#annual)</span></p><h3>Financials</h3><table class="grid"><tr><td>-</td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><td>*</td><td>Allowed <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTFinancialType.html">PCT Financial Type Code System</a>#allowed)</span></td><td><span title="US Dollar">US$1.00</span> (USD)</td><td><span title="US Dollar">US$1.00</span> (USD)</td></tr></table></blockquote></div>
  </text>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference">
    <valueReference>
      <reference value="Bundle/PCT-GFE-Bundle-Inst-1"/>
    </valueReference>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
    <valueString value="Example service"/>
  </extension>
  <identifier>
    <type>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType"/>
        <code value="uc"/>
        <display value="Unique Claim ID"/>
      </coding>
    </type>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
      <display value="Institutional"/>
    </coding>
  </type>
  <use value="predetermination"/>
  <patient>
    <reference value="Patient/patient1001"/>
  </patient>
  <created value="2021-10-12"/>
  <insurer>
    <reference value="Organization/org1001"/>
  </insurer>
  <provider>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink">
      <valueUrl value="http://example.com/out-of-network.html"/>
    </extension>
    <reference value="Organization/org1002"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <claim>
    <identifier>
      <system value="http://example.com/identifiers/bundle"/>
      <value value="59688475-2324-3242-23473847"/>
    </identifier>
  </claim>
  <outcome value="complete"/>
  <insurance>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/coverage1001"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <revenue>
      <coding>
        <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
        <code value="0611"/>
        <display
                 value="Magnetic Resonance Technology (MRT) - Brain/brain stem"/>
      </coding>
    </revenue>
    <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="2022-01-01"/>
    <net>
      <value value="200"/>
      <currency value="USD"/>
    </net>
    <adjudication>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
        <valueCodeableConcept>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"/>
            <code value="concurrent-review"/>
            <display value="Concurrent Review"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <category>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
          <code value="medicalmanagement"/>
          <display value="Medical Management"/>
        </coding>
      </category>
    </adjudication>
  </item>
  <adjudication>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS"/>
          <code value="concurrent-review"/>
          <display value="Concurrent Review"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
        <code value="medicalmanagement"/>
        <display value="Medical Management"/>
      </coding>
    </category>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
    </category>
  </adjudication>
  <adjudication>
    <category>
      <coding>
        <system
                value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
        <code value="memberliability"/>
        <display value="Member Liability"/>
      </coding>
    </category>
  </adjudication>
  <total>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
        <code value="submitted"/>
        <display value="Submitted Amount"/>
      </coding>
    </category>
    <amount>
      <value value="200"/>
      <currency value="USD"/>
    </amount>
  </total>
  <processNote>
    <extension
               url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS"/>
          <code value="disclaimer"/>
          <display value="Disclaimer"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <text value="processNote disclaimer text"/>
  </processNote>
  <benefitPeriod>
    <start value="2022-01-01"/>
    <end value="2023-01-01"/>
  </benefitPeriod>
  <benefitBalance>
    <category>
      <coding>
        <system value="https://x12.org/codes/service-type-codes"/>
        <code value="1"/>
        <display value="Medical Care"/>
      </coding>
    </category>
    <unit>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
        <code value="individual"/>
      </coding>
    </unit>
    <term>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
        <code value="annual"/>
      </coding>
    </term>
    <financial>
      <type>
        <coding>
          <system
                  value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"/>
          <code value="allowed"/>
        </coding>
      </type>
      <allowedMoney>
        <value value="1"/>
        <currency value="USD"/>
      </allowedMoney>
      <usedMoney>
        <value value="1"/>
        <currency value="USD"/>
      </usedMoney>
    </financial>
  </benefitBalance>
</ExplanationOfBenefit>