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-AEOB-1 - XML Representation

Page standards status: Informative

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <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"><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 --&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>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 --&gt; 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>
  </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>