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
| Page standards status: Informative |
{
"resourceType" : "ExplanationOfBenefit",
"id" : "PCT-AEOB-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-1</b></p><a name=\"PCT-AEOB-1\"> </a><a name=\"hcPCT-AEOB-1\"> </a><a name=\"PCT-AEOB-1-en-US\"> </a><p><b>GFE Reference</b>: <a href=\"Bundle-PCT-GFE-Bundle-Inst-1.html\">Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-23473847; type = collection; timestamp = 2021-11-09 11:01:00+0500</a></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>: <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>: 2021-10-12</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Organization Boston Radiology Center</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>claim</b>: Identifier: <code>http://example.com/identifiers/bundle</code>/59688475-2324-3242-23473847</p><p><b>outcome</b>: Processing 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><a href=\"Coverage-coverage1001.html\">Coverage: extension = insurance,false; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 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>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>: 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>United States dollar</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><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS medicalmanagement}\">Medical Management</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><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS medicalmanagement}\">Medical Management</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member Liability</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</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>United States dollar</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>: <span title=\"Codes:{https://x12.org/codes/service-type-codes 1}\">Medical Care</span></p><p><b>unit</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-unit individual}\">Individual</span></p><p><b>term</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-term annual}\">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><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType allowed}\">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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
"valueReference" : {
🔗 "reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString" : "Example service"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
"valueUrl" : "http://example.com/out-of-network.html"
}
],
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
"code" : "uc",
"display" : "Unique Claim ID"
}
]
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional",
"display" : "Institutional"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/patient1001"
},
"created" : "2021-10-12",
"insurer" : {
🔗 "reference" : "Organization/org1001"
},
"provider" : {
🔗 "reference" : "Organization/org1002"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"claim" : {
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-23473847"
}
},
"outcome" : "complete",
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/coverage1001"
}
}
],
"item" : [
{
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0611",
"display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem"
}
]
},
"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" : "2022-01-01",
"net" : {
"value" : 200,
"currency" : "USD"
},
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "medicalmanagement",
"display" : "Medical Management"
}
]
}
}
]
}
],
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSubjectToMedicalMgmtReasonCS",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "medicalmanagement",
"display" : "Medical Management"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "memberliability",
"display" : "Member Liability"
}
]
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
}
],
"processNote" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
"code" : "disclaimer",
"display" : "Disclaimer"
}
]
}
}
],
"text" : "processNote disclaimer text"
}
],
"benefitPeriod" : {
"start" : "2022-01-01",
"end" : "2023-01-01"
},
"benefitBalance" : [
{
"category" : {
"coding" : [
{
"system" : "https://x12.org/codes/service-type-codes",
"code" : "1",
"display" : "Medical Care"
}
]
},
"unit" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
"code" : "individual"
}
]
},
"term" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
"code" : "annual"
}
]
},
"financial" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
"valueMoney" : {
"value" : 0,
"currency" : "USD"
}
}
],
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"code" : "allowed"
}
]
},
"allowedMoney" : {
"value" : 1,
"currency" : "USD"
},
"usedMoney" : {
"value" : 1,
"currency" : "USD"
}
}
]
}
]
}
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-11-20
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