Patient Cost Transparency Implementation Guide
0.1.0 - ci-build

Patient Cost Transparency Implementation Guide, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Patient Cost Transparency Implementation Guide Home Page

This specification is a proposed Standard for Trial Use. It is expected to continue to evolve and improve through connectathon testing and feedback from early adopters. Note: This is an early draft or "work in progress". Therefore, changes can be expected to happen quite often and without notice.

Feedback is welcome and may be submitted through PCT Zulip indicating "US Da Vinci PCT" as the specification.

Individuals interested in participating in the Patient Cost Transparency project or other HL7 Da Vinci projects can find information about Da Vinci here.

Overview

This implementation guide (IG) defines an exchange for providers to request and receive cost information from a payer regarding a service or item. This exchange will result in an Advanced Explanation of Benefits (AEOB) which will enable a clinician and patient cost conversation. Note: This exchange will be triggered via a “request” or “scheduled service”. Also, the AEOB will include the GFE(s) (Good Faith Estimate) used to inform AEOB generation.

The goal of this IG is to support the request for cost information for specific services and items from the payer and return them in near real-time to allow effective decision making by the patient in consultation with the ‘ordering’ provider.

The project team plans to work with existing FHIR artifacts where possible. If changes are necessary, the project team will work with the responsible Work Group to review and implement (via Jira items or new PSS) any necessary enhancements to base FHIR resources, extensions, and/or profiles.

This project will reference, where possible the ‘standards’ defined by the Health Record exchange (HRex) Library/Framework Implementation Guide and other FHIR IGs where applicable.

As this is a FHIR based use case and X12 is not required. X12 will only be used to inform the PCT APIs. In other words, the implementer is not required to use X12 as there is not an HIPPA mandate to do so.

AEOB Interaction Diagram Steps

  1. A patient schedules a service which triggers the composition of a collection of 1 or more GFEs. Note: The composition of the collection of GFEs is currently not in scope for this IG. In other words the means by which the scheduling provider coordinates with other providers is currently not in scope for this IG.

  2. The collection of GFEs in the form of a FHIR resource bundle (GFE Bundle) is submitted to the payer’s intermediary or payer’s endpoint for AEOB creation.

  3. The payer’s intermediary or payer might convert the collection of GFEs to X12. Note: Converting the GFE bundle to X12 or any other format is not required to be conformant with this IG.

  4. The payer would then process, adjudicate, and produce the AEOB bundle.

  5. Once the payer has completed the adjudication of the GFEs and the creation of the AEOB. The patient (and optionally the provider) can be notified that the AEOB is ready. The payer can then deliver the AEOB to the patient (and optionally the provider) via a delivery mechanism of choice (e.g., mail, email, web portal, or other). Also, the AEOB bundle can be received via API. Note: The delivery mechanisms mentioned above are not in scope for this IG, only the API used to retrieve the AEOB bundle.

AEOB Interaction Diagram (draft)

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