Capability statement for the Da Vinci Patient Cost Transparency Implementation Guide

This operation is used by an entity to submit one or multiple GFEs as a Bundle containing the GFE(s) and other referenced resources for processing. The only input parameter is the single Bundle resource with one or multiple GFE(s) - each of which is based on the Claim resource (along with other referenced resources). The only output is a url for subsequent polling per async pattern. If after polling the response is complete, then the result will either be a single Bundle with the AEOB - which is based on the ExplanationOfBenefit resource, (and other referenced resources) or an OperationOutcome resource indicating the AEOB will be sent directly to the patient and not to the provider.

Select planned date of service

OperationOutcome returned from the gfeSubmit operation when there are adjudication errors during AEOB processing

PCT AEOB Bundle that contains necessary resources for an AEOBs. Organizations for both the payer and provider SHALL be included.

OperationOutcome returned from the gfeSubmit operation when the AEOB process is complete but no AEOB will be returned to the submitter (i.e. it was sent only to the patient)

The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.

PCT Coverage is a profile for capturing data that reflect a payer’s coverage that was effective as of the proposed date of service or the date of admission of the GFE.

PCT GFE Bundle that contains necessary resources as a GFE Submission for obtaining an AEOB. Organizations for both the provider and payer SHALL be included. The scope of this guide does not include coordination of benefits or more than one coverage. This does not serve as a replacement for eligibility, prior authorization or other financial and administrative use cases.

OperationOutcome returned from the gfeSubmit operation when the GFE Bundle fails FHIR validation

PCT Good Faith Estimate Institutional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for an institutional GFE submission.

PCT Good Faith Estimate Professional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for a professional GFE submission.

The PCT Organization profile builds upon the US Core Organization profile. It is used to convey a payer, provider, payee, or service facility organization.

The PCT Practitioner profile builds upon the US Core Practitioner profile. It is used to convey information about the practitioner who will be providing services to the patient as described on the GFE.

The quantity of the benefit remaining to date.

This extension is used to provide the Country Subdivision Code - from Part 2 of ISO 3166.

This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB.

This extension is used by the provider to assign a unique identifier to this item. The intent of this element is to allow the provider to assign something other than ‘line number’ for their purposes (e.g. tracking and troubleshooting).

If the provider has received a written consent form indicating a patient has agreed to waive their protections and pay up to the full cost for the out-of-network item or service, this will be “true”. If the provider has not received written consent, this will be “false”. This is an attestation only. The billing provider is legally required to maintain the written notice and consent form.

Disclaimers the patient should be made aware of regarding the providers estimate

This extension is used to provide the GFE Service Linking Information. This allows implementers to have the same identifier on multiple GFEs that are part of one period of care’s services. This would be needed for some of the workflow options that businesses may decide to use.

This extension is used to indicate the scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB. All submitters (Practitioners and Organizations) must have an ETIN.

This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services.

This extension is used to provide an endpoint.

This extension is used to indicate a the class of AEOB Claim process notes

This extension is used for indicating the method a provider used to group services, and those providing such services, beyond what may be indicated through DRGs that the payer or patient may find helpful (e.g. grouping services by a standardized episode of care definition). This is provider generated text and should not be modified by the payer.

This extension is used to indicate the taxonomy code of the provider.

This extension is used to provide the Referral Number.

This extension is used to communicate a plain language description of the procedure, product, or service.

This extension is used to provide a reason to explain how the estimate may change subject to medical management.

CPT - HCPCS - HIPPS codes to report medical procedures and services under public and private health insurance programs

Procedure Codes from https://www.cms.gov/Medicare/Coding/ICD10

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially.

There are no gaps because all used and unused codes are identified. This value set consists of the following:

• FL 15 - Point of Origin for Admission or Visit for Non-newborn
• FL 15 - Point of Origin for Admission or Visit for Newborn

These codes are used to convey the patient point of origin for an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here Statement of Understanding between AHA and HL7 can be found here. In particular see sections 4.1d and 4.2.

The UB-04 Manual has a 12-month subscription period from June 30 through July 1.

For frequently asked questions, see here here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This value set consists of the following:

• FL 14 - Priority (Type) of Admission or Visit

These codes are used to convey the priority of an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here

Statement of Understanding between AHA and HL7 can be found here. In particular see sections 4.1d and 4.2.

The UB-04 Manual has a 12-month subscription period from June 30 through July 1.

For frequently asked questions, see here here

This Code system is referenced in the content logical definition of the following value sets:

This CodeSystem is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

This code system https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit defines many codes, but they are not represented here

Indicates the type of .processNote for AEOB.

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

Codes indicating reasons why a claim or line item is adjusted.

Codes to specify the type of AEOB

Combination of CMS HCPCS and AMA CPT codes to specify the type of surgical procedure

Codes to specify the the functional roles of the care team members.

Codes to specify the type of diagnosis

Financial Type codes for benefitBalance.financial.type.

CMS Place of Service codes

These codes in this value set are derived from the NUBC Uniform Billing (UB-04) Type of Bill (TOB) codes. The fourth digit of the TOB code defines the frequency of the bill for the institutional and electronic professional claim.

Value Set containing codes for the type of adjudication information provided.

CPT - HCPCS codes to report medical procedures and services under public and private health insurance programs

The FDA published list of NDC codes for finished drug products

NUBC UB-04 Revenue codes

NUBC Uniform Billing (UB-04) codes to indicate the specific Type of Bill (TOB), e.g., hospital inpatient, outpatient, replacements, voids, etc. The first digit is a leading zero*. The fourth digit defines the frequency of the bill for the institutional and electronic professional claim.

ICD-10 Codes to specify the type of diagnosis

Codes for the classification of organization contact purposes

Codes to specify the type of identifiers for organizations to indicate usage for a specific purpose

Codes to specify the type of entity involved in the PCT GFE process

Indicates the in network or out of network payment status of the claim or line item.

Indicates the Provider network status with the Payer as of the effective date of service or admission.

Codes to specify the type of procedure

Codes for the classification of subject-to-medical-management reasons

Codes to specify the type of the supplied supporting information

Category codes for PCT benefitBalance.category from X12 service type.

US Claim Diagnosis Related Group Codes. All codes from MS-DRGs - AP-DRGs - APR-DRGs

Defining codes for process notes. This is for trial use.

Codes indicating the type of adjudication information provided.

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

PCT code system for defining the functional roles of the care team members.

Defining codes for the classification of diagnosis types

Financial Type codes for benefitBalance.financial.type.

These codes are derived from the NUBC Uniform Billing (UB-04) Type of Bill (TOB) codes. The fourth digit of the TOB code defines the frequency of the bill for the institutional and electronic professional claim.

Defining codes for the classification of the supplied supporting information

Defining codes for types of identifiers

Defining codes for network status. This is for trial use.

Organization Contact Purpose Type Code System

Identifier Type codes for defining the type of identifier payers and providers assign to organizations

Defining codes for the classification of procedure types

Defining codes for the classification of subject-to-medical-management reason types

An instance of the PCTAdvancedEOB Profile

PCT AEOB Adjudication Error Example 1

PCT AEOB Bundle Example 1

PCT AEOB Complete Example 1

PCT GFE Bundle Institutional Example 1

PCT GFE Bundle Professional Example 1

PCT Institutional GFE Example 1

PCT Institutional GFE for MRI

PCT Professional GFE Example 1

PCT GFE Validation Error Example 1

Institutional GFE Submitter 1

Professional GFE Submitter 1

An instance of Contract

An instance of PCTCoverage

An instance of Endpoint

An instance of PCTOrganization as a payer

An instance of PCTOrganization as a healthcare provider

An instance of Patient

An instance of PCTPractitioner

An instance of PCTPractitioner