Patient Cost Transparency Implementation Guide
0.1.0 - ci-build

Patient Cost Transparency Implementation Guide, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide

GFESubmitOperation

This operation is used by an entity to submit one or multiple GFEs as a Bundle containing the GFE(s) and other referenced resources for processing. The only input parameter is the single Bundle resource with one or multiple GFE(s) - each of which is based on the Claim resource, (along with other referenced resources) and the only output is a single Bundle with the AEOB - which is based on the ExplanationOfBenefit resource, (and other referenced resources) or an OperationOutcome resource.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

PCT AEOB Bundle

PCT AEOB Bundle that contains necessary resources for an AEOBs. Organizations for both the payer and provider SHALL be included.

PCT Advanced EOB

The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.

PCT Coverage

PCT Coverage is a profile for capturing data that reflect a payer’s coverage that was effective as of the proposed date of service or the date of admission of the GFE.

PCT GFE Bundle

PCT GFE Bundle that contains necessary resources as a GFE Submission for obtaining an AEOB. Organizations for both the provider and payer SHALL be included.

PCT Good Faith Estimate Institutional

PCT Good Faith Estimate Institutional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for an institutional GFE submission.

PCT Good Faith Estimate Professional

PCT Good Faith Estimate Professional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for a professional GFE submission.

PCT Location

The PCT Location profile builds upon the US Core Location profile and is used with other PCT profile resources.

PCT Organization

The PCT Organization profile builds upon the US Core Organization profile. It is used to convey a payer, provider, payee, or service facility organization.

PCT Patient

The PCT Patient profile builds upon the US Core Patient profile. It is used to convey information about the patient who will be receiving the services as described on the GFE.

PCT Practitioner

The PCT Practitioner profile builds upon the US Core Practitioner profile. It is used to convey information about the practitioner who will be providing services to the patient as described on the GFE.

PCT PractitionerRole

The PCT PractitionerRole profile builds upon the US Core PractitionerRole profile. It is used to convey information about the practitioner who will be providing services to the patient as described on the GFE.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide

CompoundDrugLinkingNumber

This extension is used to provide the Compound Drug Linking Number.

CountrySubdivisionCode

This extension is used to provide the Country Subdivision Code - from Part 2 of ISO 3166.

Disclaimer

This extension allows the payer to declare a disclaimer concerning the estimated costs provided in the AEOB.

EstimatedDateOfService

This extension is used to provide the estimated date or dates of service or product delivery

Expiration Date

This extension is used to indicate a specific date after which the issued AEOB is considered obsolete.

GFEBillingProviderLineItemCtrlNum

This extension is used to provide the GFE Billing Provider Line Item Control Number.

GFEProviderAssignedIdentifier

This extension is used to indicate the GFE Provider Assigned Identifier.

GFE Reference

This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB.

GFEServiceLinkingInfo

This extension is used to provide the GFE Service Linking Information.

GFESubmitter

This extension is used to indicate the scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB.

InterTransIdentifier

This extension is used to provide the GFE Service Identifier for Transmission Intermediaries.

Out Of Network Provider Info

This extension is used to provide a reference to a web site for finding information on the out-of-network provider.

PCTEndpoint

This extension is used to provide an endpoint.

ProviderEventMethodology

This extension is used for indicating how the provider determined the number of providers involved–through internal experience/analysis or an external methodology.

ProviderTaxonomy

This extension is used to indicate the taxonomy code of the provider.

ReferralNumber

This extension is used to provide the Referral Number.

Subject To Medical Management

This extension is used to provide a reason to explain how the estimate may change subject to medical management.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

PCT Care Team Role Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the the functional roles of the care team members.

PCT Coverage Copay Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes for the classification of insurance coverage copay types for patient. This is an extension of the CoverageCopayTypeCodes value set

PCT Diagnosis Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of diagnosis

PCT ICD-10 Diagnostic Codes

ICD-10 Codes to specify the type of diagnosis

PCT GFE CMS Place of Service Value Set

CMS Place of Service codes

PCT GFE Item Adjudication Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Sample Adjudication codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.

PCT GFE Item CPT - HCPCS - HIPPS Value Set

CPT - HCPCS - HIPPS codes to report medical procedures and services under public and private health insurance programs

PCT GFE Item CPT - HCPCS Value Set

CPT - HCPCS codes to report medical procedures and services under public and private health insurance programs

PCT GFE Item NDC Value Set

The FDA published list of NDC codes for finished drug products

PCT GFE NUBC Revenue Value Set

NUBC UB-04 Revenue codes

PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set

NUBC Uniform Billing (UB-04) codes to indicate the specific Type of Bill (TOB), e.g., hospital inpatient, outpatient, replacements, voids, etc. The first digit is a leading zero*. The fourth digit defines the frequency of the bill for the institutional and electronic professional claim.

PCT Organization Contact Purpose Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes for the classification of organization contact purposes

PCT Organization Identifier Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of identifiers for organizations to indicate usage for a specific purpose

PCT Organization Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of entity involved in the PCT GFE process

PCT CMS HCPCS and AMA CPT Procedure Surgical Codes

Combination of CMS HCPCS and AMA CPT codes to specify the type of surgical procedure

PCT Procedure Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of procedure

PCT Subject-To-Medical-Management Reason Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes for the classification of subject-to-medical-management reasons

PCT Supporting Info Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Codes to specify the type of the supplied supporting information

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

PCT Adjudication Category Type

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

PCT Care Team Role

PCT code system for defining the functional roles of the care team members.

PCT Coverage Copay Type Code System

Defining codes for the classification of insurance coverage copay types for patient

PCT Diagnosis Type

Defining codes for the classification of diagnosis types

PCT GFE Item Procedure Code System

Defining codes to report medical procedures and services under public and private health insurance programs

PCT GFE Item Revenue Code System

Defining codes to report medical procedures and services under public and private health insurance programs

PCT GFE Type Of Bill Code System

Defining codes to indicate the specific Type of Bill (TOB)

PCT Organization Contact Purpose Type Code System

Organization Contact Purpose Type Code System

PCT Organization Identifier Type Code System

Identifier Type codes for defining the type of identifier payers and providers assign to organizations

PCT Organization Type Code System

Organization Type codes for describing the type of organizations involved in the PCT GFE process

PCT Procedure Surgical Code System

Defining codes for the classification of surgical procedure types

PCT Procedure Type

Defining codes for the classification of procedure types

PCT Subject-To-Medical-Management Reason Code System

Defining codes for the classification of subject-to-medical-management reason types

PCT GFE Supporting Info Type Code System

Defining codes for the classification of the supplied supporting information

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

PCT-AEOB-1

An instance of the PCTAdvancedEOB Profile

PCT-AEOB-Bundle-1

PCT AEOB Bundle Example 1

PCT-GFE-Bundle-Inst-1

PCT GFE Bundle Institutional Example 1

PCT-GFE-Bundle-Prof-1

PCT GFE Bundle Professional Example 1

PCT-GFE-Institutional-1

PCT Institutional GFE Example 1

PCT-GFE-Professional-1

PCT Professional GFE Example 1

Provider-Org-Loc-2

An instance of PCTLocation

Submitter-Org-1

Institutional GFE Submitter 1

Submitter-Practitioner-1

Professional GFE Submitter 1

contract1001

An instance of Contract

coverage1001

An instance of PCTCoverage

endpoint001

An instance of Endpoint

org1001

An instance of PCTOrganization as a payer

org1002

An instance of PCTOrganization as a healthcare provider

patient1001

An instance of Patient

prac001

An instance of PCTPractitioner

prac002

An instance of PCTPractitioner

pracRole002

An instance of PCTPractitionerRole