Patient Cost Transparency Implementation Guide
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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

: PCT-GFE-Institutional-MRI - XML Representation

Page standards status: Informative

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<Claim xmlns="http://hl7.org/fhir">
  <id value="PCT-GFE-Institutional-MRI"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim PCT-GFE-Institutional-MRI</b></p><a name="PCT-GFE-Institutional-MRI"> </a><a name="hcPCT-GFE-Institutional-MRI"> </a><a name="PCT-GFE-Institutional-MRI-en-US"> </a><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001MRI</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}">Institutional</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href="Patient-patient1001.html">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>created</b>: 2022-02-02</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href="Organization-Submitter-Org-1.html">Organization GFE Service Help INC.</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">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><span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Provider</span></td></tr></table><p><b>referral</b>: Referral Number</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><span title="Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType typeofbill}">Type of Bill</span></td><td><span title="Codes:{https://www.nubc.org/CodeSystem/TypeOfBill example-bill-type}">example-bill-type</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><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.30}">Unspecified focal traumatic brain injury</span></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}">Principal Diagnosis</span></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup 400}">Head trauma - concussion</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: extension = No display for Extension ,No display for Extension ; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --&gt; 2022-01-01</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0611}">Magnetic Resonance Technology (MRT) - Brain/brain stem</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.ama-assn.org/go/cpt 70551}">Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material</span></p><p><b>serviced</b>: 2022-02-02</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>266</td><td>United States dollar</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>266</td><td>United States dollar</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/gfeServiceLinkingInfo">
    <extension url="linkingIdentifier">
      <valueString value="223452-2342-2435-008002"/>
    </extension>
    <extension url="plannedPeriodOfService">
      <valueDate value="2022-02-02"/>
    </extension>
  </extension>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="PLAC"/>
        <display value="Placer Identifier"/>
      </coding>
    </type>
    <value value="GFEProviderAssignedID0001MRI"/>
  </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="2022-02-02"/>
  <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>
    <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="REF12022002-122"/>
    </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="example-bill-type"/>
      </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>
    <servicedDate value="2022-02-02"/>
    <quantity>
      <value value="1"/>
    </quantity>
    <net>
      <value value="266"/>
      <currency value="USD"/>
    </net>
  </item>
  <total>
    <value value="266"/>
    <currency value="USD"/>
  </total>
</Claim>