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-Professional-MRI - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "PCT-GFE-Professional-MRI",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PCT-GFE-Professional-MRI</b></p><a name=\"PCT-GFE-Professional-MRI\"> </a><a name=\"hcPCT-GFE-Professional-MRI\"> </a><a name=\"PCT-GFE-Professional-MRI-en-US\"> </a><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0002</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}\">Professional</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>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href=\"Practitioner-Submitter-Practitioner-1.html\">Practitioner Nora Ologist</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>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>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>modifier</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>: 2021-10-31</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">Inpatient Hospital</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</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>United States dollar</td></tr></table><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>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>200</td><td>United States dollar</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
      "valueString" : "EEMM1022"
    },
    {
      "extension" : [
        {
          "url" : "linkingIdentifier",
          "valueString" : "223452-2342-2435-008001"
        },
        {
          "url" : "plannedPeriodOfService",
          "valueDate" : "2021-10-31"
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
    }
  ],
  "identifier" : [
    {
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "PLAC",
            "display" : "Placer Identifier"
          }
        ]
      },
      "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
      "value" : "GFEProviderAssignedID0002"
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "professional",
        "display" : "Professional"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    🔗 "reference" : "Patient/patient1001"
  },
  "created" : "2021-10-05",
  "insurer" : {
    🔗 "reference" : "Organization/org1001"
  },
  "provider" : {
    🔗 "extension" : [
      {
        "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy",
        "valueCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://nucc.org/provider-taxonomy",
              "code" : "2085D0003X",
              "display" : "Diagnostic Neuroimaging (Radiology) Physician"
            }
          ]
        }
      }
    ],
    "reference" : "Practitioner/Submitter-Practitioner-1"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "payee" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
          "code" : "provider"
        }
      ]
    }
  },
  "referral" : {
    "extension" : [
      {
        "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber",
        "valueString" : "REF12022002-122"
      }
    ],
    "display" : "Referral Number"
  },
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10-cm",
            "code" : "S06.30",
            "display" : "Unspecified focal traumatic brain injury"
          }
        ]
      },
      "type" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
              "code" : "principal"
            }
          ]
        }
      ],
      "packageCode" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
            "code" : "400",
            "display" : "Head trauma - concussion"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/coverage1001"
      }
    }
  ],
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
          "valueString" : "Imaging"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum",
          "valueIdentifier" : {
            "value" : "GFEBillingProviderLineItemCtrlNum-0001"
          }
        }
      ],
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.ama-assn.org/go/cpt",
            "code" : "70551",
            "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
          }
        ]
      },
      "modifier" : [
        {
          "coding" : [
            {
              "system" : "http://www.ama-assn.org/go/cpt",
              "code" : "70551",
              "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
            }
          ]
        }
      ],
      "servicedDate" : "2021-10-31",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code" : "21",
            "display" : "Inpatient Hospital"
          }
        ]
      },
      "quantity" : {
        "value" : 1
      },
      "unitPrice" : {
        "value" : 200,
        "currency" : "USD"
      },
      "net" : {
        "value" : 200,
        "currency" : "USD"
      }
    }
  ],
  "total" : {
    "value" : 200,
    "currency" : "USD"
  }
}