Patient Cost Transparency Implementation Guide
2.0.0 - STU 2 United States of America flag

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v2.0.0: STU 2) based on FHIR (HL7® FHIR® Standard) 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

Example Claim: PCT-GFE-Institutional-1

Page standards status: Informative

ProviderEventMethodology: EEMM1021

GFEDisclaimer: For estimation purposes only

GFEServiceLinkingInfo

  • linkingIdentifier: http://example.org/Claim/identifiers/223452-2342-2435-008001
  • plannedPeriodOfService: 2021-10-31

identifier: Placer Identifier/GFEProviderAssignedID0001

status: Active

type: Institutional

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: Organization GFE Service Help INC.

priority: Normal

Payees

-Type
*Provider

referral: Referral Number

SupportingInfos

-SequenceCategoryCode
*1Type of BillHospital Inpatient (Part A)

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injuryPrincipal DiagnosisHead trauma - concussion

Insurances

-SequenceFocalCoverage
*1trueCoverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

item

Service Description: Imaging

sequence: 1

revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem

productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

serviced: 2021-10-31

quantity: 1

Nets

-ValueCurrency
*200United States dollar

Totals

-ValueCurrency
*200United States dollar