Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="PCT-AEOB-Bundle-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-1234567"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-10T11:01:00+05:00"/>
<entry id="PCT-AEOB-Summary-1">
<fullUrl
value="http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1"/>
<resource>
<ExplanationOfBenefit>
<id value="PCT-AEOB-Summary-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ExplanationOfBenefit_PCT-AEOB-Summary-1"> </a><p><b>Generated Narrative: ExplanationOfBenefit</b><a name="PCT-AEOB-Summary-1"> </a><a name="hcPCT-AEOB-Summary-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 "PCT-AEOB-Summary-1" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-aeob-summary.html">PCT Advanced EOB Summary</a></p></div><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href="http://example.com/out-of-network.html">http://example.com/out-of-network.html</a></p><p><b>status</b>: active</p><p><b>type</b>: Estimate Summary <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-PCTEstimateTypeSummaryCSTemporaryTrialUse.html">PCT Estimate Type Code System</a>#estimate-summary)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: See on this page: Patient/patient1001</p><p><b>billablePeriod</b>: 2022-01-01 --> 2022-01-01</p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: See on this page: Organization/org1001</p><p><b>provider</b>: <span>??</span></p><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td>See on this page: Coverage/coverage1001</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/5.3.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></blockquote><h3>ProcessNotes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --> 2022-01-01</p><blockquote><p><b>benefitBalance</b></p><p><b>category</b>: Medical Care <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-X12ServiceTypeCodes.html">X12 Service Type Codes</a>#1)</span></p><p><b>unit</b>: Individual <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/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/5.3.0/CodeSystem-benefit-term.html">Benefit Term Codes</a>#annual)</span></p><h3>Financials</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><td style="display: none">*</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">$1.00</span> (USD)</td><td><span title="US Dollar">$1.00</span> (USD)</td></tr></table></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
<valueString value="Example service"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink">
<valueUrl value="http://example.com/out-of-network.html"/>
</extension>
<status value="active"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
<code value="estimate-summary"/>
<display value="Estimate Summary"/>
</coding>
</type>
<use value="predetermination"/>
<patient>🔗
<reference value="Patient/patient1001"/>
</patient>
<billablePeriod>
<start value="2022-01-01"/>
<end value="2022-01-01"/>
</billablePeriod>
<created value="2021-10-12"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
<valueCode value="not-applicable"/>
</extension>
</provider>
<outcome value="complete"/>
<insurance>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<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="2022-01-01"/>
</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>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit">
<valueMoney>
<value value="0"/>
<currency value="USD"/>
</valueMoney>
</extension>
<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>
</resource>
</entry>
<entry id="PCT-AEOB-1">
<fullUrl value="http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1"/>
<resource>
<ExplanationOfBenefit>
<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"><a name="ExplanationOfBenefit_PCT-AEOB-1"> </a><p><b>Generated Narrative: ExplanationOfBenefit</b><a name="PCT-AEOB-1"> </a><a name="hcPCT-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 "PCT-AEOB-1" </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>: See on this page: Bundle/PCT-GFE-Bundle-Inst-1</p><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href="http://example.com/out-of-network.html">http://example.com/out-of-network.html</a></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/5.3.0/CodeSystem-claim-type.html">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: See on this page: Patient/patient1001</p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: See on this page: Organization/org1001</p><p><b>provider</b>: <a href="Organization-org1002.html">Organization/org1002</a> "Boston Radiology Center"</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><p><b>claim</b>: <span><code>http://example.com/identifiers/bundle</code>/59688475-2324-3242-23473847</span></p><p><b>outcome</b>: complete</p><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td>See on this page: Coverage/coverage1001</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/5.3.0/CodeSystem-AHANUBCRevenueCodes.html">AHA NUBC Revenue Codes</a>#0611)</span></p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>modifier</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/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 style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style="display: none">*</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 style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style="display: none">*</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 style="display: none">*</td><td> </td><td>Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></td></tr><tr><td style="display: none">*</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/5.3.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</span></p><h3>Amounts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></blockquote><h3>ProcessNotes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --> 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"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-X12ServiceTypeCodes.html">X12 Service Type Codes</a>#1)</span></p><p><b>unit</b>: Individual <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/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/5.3.0/CodeSystem-benefit-term.html">Benefit Term Codes</a>#annual)</span></p><h3>Financials</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><td style="display: none">*</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">$1.00</span> (USD)</td><td><span title="US Dollar">$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>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink">
<valueUrl value="http://example.com/out-of-network.html"/>
</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>🔗
<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); without contrast material"/>
</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); without contrast material"/>
</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>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit">
<valueMoney>
<value value="0"/>
<currency value="USD"/>
</valueMoney>
</extension>
<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>
</resource>
</entry>
<entry id="patient1001">
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry id="coverage1001">
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="coverage1001"></a><a name="hccoverage1001"></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 Coverage "coverage1001"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> " BETTERHALF"</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization/org1001</a> "Umbrella Insurance Company"</p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td>Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Copay Percentage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
<valueBoolean value="false"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
<entry id="org1001">
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1001"></a><a name="hcorg1001"></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 Organization "org1001"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US</p></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-CT"/>
</valueCoding>
</extension>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="PCT-GFE-Bundle-Inst-1">
<fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1"/>
<resource>
<Bundle>
<id value="PCT-GFE-Bundle-Inst-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-23473847"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-09T11:01:00+05:00"/>
<entry id="PCT-GFE-Summary-1">
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Summary-1"/>
<resource>
<Claim>
<id value="PCT-GFE-Summary-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="PCT-GFE-Summary-1"></a><a name="hcPCT-GFE-Summary-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 Claim "PCT-GFE-Summary-1"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-gfe-summary.html">PCT Good Faith Estimate Summary</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Estimate Summary <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTEstimateTypeSummaryCSTemporaryTrialUse.html">PCT Estimate Type Code System</a>#estimate-summary)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> " BETTERHALF"</p><p><b>billablePeriod</b>: 2021-10-31 --> 2021-10-31</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization/org1001</a> "Umbrella Insurance Company"</p><p><b>provider</b>: <span>??</span></p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><h3>Totals</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></div>
</text>
<status value="active"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
<code value="estimate-summary"/>
<display value="Estimate Summary"/>
</coding>
</type>
<use value="predetermination"/>
<patient>🔗
<reference value="Patient/patient1001"/>
</patient>
<billablePeriod>
<start value="2021-10-31"/>
<end value="2021-10-31"/>
</billablePeriod>
<created value="2021-10-05"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
<valueCode value="not-applicable"/>
</extension>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display
value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry id="PCT-GFE-Institutional-1">
<fullUrl
value="http://example.org/fhir/Claim/PCT-GFE-Institutional-1"/>
<resource>
<Claim>
<id value="PCT-GFE-Institutional-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="PCT-GFE-Institutional-1"></a><a name="hcPCT-GFE-Institutional-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 Claim "PCT-GFE-Institutional-1"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-gfe-institutional.html">PCT Good Faith Estimate Institutional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1021</p><p><b>GFEDisclaimer</b>: For estimation purposes only</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008001</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2021-10-31</p></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001</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/5.3.0/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> " BETTERHALF"</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization/org1001</a> "Umbrella Insurance Company"</p><p><b>provider</b>: <a href="Organization-Submitter-Org-1.html">Organization/Submitter-Org-1</a> "GFE Service Help INC."</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html">Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Type of Bill <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTSupportingInfoType.html">PCT GFE Supporting Info Type Code System</a>#typeofbill)</span></td><td>Hospital Inpatient (Part A) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCTypeOfBill.html">AHA NUBC Type Of Bill Codes</a>#011X)</span></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-coverage1001.html">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</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/5.3.0/CodeSystem-AHANUBCRevenueCodes.html">AHA NUBC Revenue Codes</a>#0611)</span></p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>modifier</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>serviced</b>: 2021-10-31</p><p><b>quantity</b>: 1</p><h3>Nets</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></blockquote><h3>Totals</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>200</td><td>USD</td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
<valueString value="EEMM1021"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer">
<valueString value="For estimation purposes only"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
<extension url="linkingIdentifier">
<valueString value="223452-2342-2435-008001"/>
</extension>
<extension url="plannedPeriodOfService">
<valueDate value="2021-10-31"/>
</extension>
</extension>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PLAC"/>
<display value="Placer Identifier"/>
</coding>
</type>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<value value="GFEProviderAssignedID0001"/>
</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="2021-10-05"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>🔗
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
<valueCodeableConcept>
<coding>
<system value="http://nucc.org/provider-taxonomy"/>
<code value="2085D0003X"/>
<display
value="Diagnostic Neuroimaging (Radiology) Physician"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling">
<valueBoolean value="true"/>
</extension>
<reference value="Organization/Submitter-Org-1"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
</payee>
<referral>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
<valueString value="REF12022002-121"/>
</extension>
<display value="Referral Number"/>
</referral>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType"/>
<code value="typeofbill"/>
</coding>
</category>
<code>
<coding>
<system
value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
<code value="011X"/>
<display value="Hospital Inpatient (Part A)"/>
</coding>
</code>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display
value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
<valueString value="Imaging"/>
</extension>
<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); without contrast material"/>
</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); without contrast material"/>
</coding>
</modifier>
<servicedDate value="2021-10-31"/>
<quantity>
<value value="1"/>
</quantity>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
</item>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry id="Submitter-Org-1">
<fullUrl
value="http://example.org/fhir/Organization/Submitter-Org-1"/>
<resource>
<Organization>
<id value="Submitter-Org-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="Submitter-Org-1"></a><a name="hcSubmitter-Org-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 Organization "Submitter-Org-1"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-10010301</p><p><b>active</b>: true</p><p><b>type</b>: Non-Healthcare Business or Corporation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#bus)</span></p><p><b>name</b>: GFE Service Help INC.</p><h3>Contacts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Purpose</b></td><td><b>Name</b></td><td><b>Telecom</b></td></tr><tr><td style="display: none">*</td><td>GFE-related <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="CodeSystem-PCTOrgContactPurposeType.html">PCT Organization Contact Purpose Type Code System</a>#GFERELATED)</span></td><td>Clara Sender</td><td>ph: 781-632-3209(WORK), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></td></tr></table></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-10010301"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="bus"/>
</coding>
</type>
<name value="GFE Service Help INC."/>
<contact>
<purpose>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType"/>
<code value="GFERELATED"/>
</coding>
</purpose>
<name>
<text value="Clara Sender"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-632-3209"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="csender@GFEServiceHelp.com"/>
<use value="work"/>
</telecom>
</contact>
</Organization>
</resource>
</entry>
<entry id="org1001">
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1001"></a><a name="hcorg1001"></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 Organization "org1001"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: Payer <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html">Organization type</a>#pay)</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(WORK)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US</p></div>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-CT"/>
</valueCoding>
</extension>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="patient1001">
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="coverage1001"></a><a name="hccoverage1001"></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 Coverage "coverage1001"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> " BETTERHALF"</p><p><b>relationship</b>: Self <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization/org1001</a> "Umbrella Insurance Company"</p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td>Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html">Coverage Class Codes</a>#plan)</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Copay Percentage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(<a href="http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
<valueBoolean value="false"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
</Bundle>
</resource>
</entry>
</Bundle>
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-08
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