Coordination Platform Capability Statement for the Da Vinci Patient Cost Transparency Implementation Guide

Coordination Requester Capability Statement for the Da Vinci Patient Cost Transparency Implementation Guide

GFE Contributor Capability Statement for the Da Vinci Patient Cost Transparency Implementation Guide

Payer capability statement for the Da Vinci Patient Cost Transparency Implementation Guide

This operation is used by an entity to retrieve a GFE Collection Bundle containing the GFE Bundle(s) and other referenced resources based on a GFE Coordination Task. The only input parameter is the single reference to the coordination task resource. The only output is a GFE Collection Bundle. If the task reference is to a Coordinating Task, this will return the GFE Collection Bundle. If this task reference is for a GFE Contributor Task, it returns the GFE Bundle, if present. If a GFE Bundle does not exist for an associated Contributor Task, in place of a GFE Bundle, a GFE Missing Bundle is provided (either directly in a response if the referenced task was a Contributor Task or inside the GFE Collection Bundle if the referenced task was a Coordinating Task.)

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). The only output is a url for subsequent polling per async pattern. If after polling the response is complete, then the result will either be a single Bundle with the AEOB - which is based on the ExplanationOfBenefit resource, (and other referenced resources) or an OperationOutcome resource indicating the AEOB will be sent directly to the patient and not to the provider.

Select planned date of service

Completed or terminated task(s) whose function is taken by this new task

Search for a task by when the task should be performed

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.

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

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 GFE Bundle that contains all resources for a Good faith estimate submitted by a single GFE contributing provider. Organizations for both the provider and payer MAY be included. This single contributing provider GFE Bundle may be included in a set of GFE bundles from other providers in a GFE Collection Bundle that can then be made available to the patient or sent to a payer for insurance estimation. The scope of this guide does not include coordination of benefits for more than one coverage. This does not serve as a replacement for eligibility, prior authorization or other financial and administrative use cases.

PCT GFE Collection Bundle that contains GFE Bundles from GFE contributors. This collection of GFE Bundles from GFE contributors that can then be made available to the patient or sent to a payer for insurance estimation. The scope of this guide does not include coordination of benefits or more than one coverage. This does not serve as a replacement for eligibility, prior authorization or other financial and administrative use cases.

The PCT GFE Contributor Task is used by a GFE coordinator to assign a GFE contributor task to a specific provider and may include information specific to that patient’s expected service

PCT GFE Request Bundle that contains necessary resources for GFE to request GFEs from one or multiple GFE contributing providers.

The Good Faith Estimate (GFE) Coordination Task is used to organize a GFE across providers for a single period of care for which all GFE Contributor Task resources will be linked. The task includes the general inputs that are shared across all of the GFE contributor tasks. These inputs may include a ‘primary’ service and relevant conditions.

The PCT DeviceRequest including details about a device for which a GFE is being requested.

PCT GFE Information Bundle that contains the information necessary for GFE contributors to create their estimates. This bundle may for all GFE Contributors or specific to a single contributor and may include, but is not limited to, the Patient Resource, request resources (such as ServiceRequest, MedicationRequest, and DeviceRequest), Service location information, Coverage and Payer Organization resources (if applicable).

The PCT MedicationRequest including details about a medication for which a GFE is being requested.

PCT GFE Missing Bundle is used to indicate when a GFE Contributor task request was made, but no GFE Bundle was submitted (attached to the ContributorTask).

The PCT ServiceRequest including details about a service for which a GFE is being requested.

PCT Good Faith Estimate Summary is a profile for summarizing costs associated with a set of Good Faith Estimate Claims for a single Period of Care.

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 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.

The PCT Service Location provides information where the service is to be performed or the item delivered. This could be used to express an actual physical location or a facility type.

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.

This profile is used for exchanging a summary of Explanation of Benefit (EoB) information, including costs and benefits, of all of the Advanced EoB data contained within an Advance EoB Bundle.

OperationOutcome returned from the gfeSubmit operation when there are adjudication errors during AEOB processing

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

OperationOutcome returned from the gfeSubmit operation when the AEOB process is complete but no AEOB will be returned to the submitter (i.e. it was sent only to the patient)

OperationOutcome returned from the gfeSubmit operation when the GFE Bundle fails FHIR validation

The quantity of the benefit remaining to date.

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

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

This extension is used by the provider to assign a unique identifier to this item. The intent of this element is to allow the provider to assign something other than 'line number' for their purposes (e.g. tracking and troubleshooting).

If the provider has received a written consent form indicating a patient has agreed to waive their protections and pay up to the full cost for the out-of-network item or service, this will be “true”. If the provider has not received written consent, this will be “false”. This is an attestation only. The billing provider is legally required to maintain the written notice and consent form.

Disclaimers the patient should be made aware of regarding the providers estimate

This extension is used to provide the GFE Service Linking Information. This allows implementers to have the same identifier on multiple GFEs that are part of one period of care's services. This would be needed for some of the workflow options that businesses may decide to use.

This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services.

This extension is used to provide an endpoint.

Planned period of service the request is about

This extension is used to indicate a the class of AEOB Claim process notes

This extension is used for indicating the method a provider used to group services, and those providing such services, beyond what may be indicated through DRGs that the payer or patient may find helpful (e.g. grouping services by a standardized episode of care definition). This is provider generated text and should not be modified by the payer.

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

This extension is used to provide the Referral Number.

Instant from which the request is being initiated.

Requester has explicitly declared self-pay.

This extension is used to communicate a plain language description of the procedure, product, or service.

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

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

Codes allowed for a GFE Coordination Task status

Procedure Codes from https://www.cms.gov/Medicare/Coding/ICD10

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially.

There are no gaps because all used and unused codes are identified. This value set consists of the following:

• FL 15 - Point of Origin for Admission or Visit for Non-newborn
• FL 15 - Point of Origin for Admission or Visit for Newborn

These codes are used to convey the patient point of origin for an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here Statement of Understanding between AHA and HL7 can be found here. In particular see sections 4.1d and 4.2.

The UB-04 Manual has a 12-month subscription period from June 30 through July 1.

For frequently asked questions, see here here

The UB-04 Data File contains the complete set of NUBC codes. Every code in the range of possible codes is accounted for sequentially. There are no gaps because all used and unused codes are identified.

This value set consists of the following:

• FL 14 - Priority (Type) of Admission or Visit

These codes are used to convey the priority of an admission or visit and are the property of the American Hospital Association.

To obtain the underlying code systems, please see information here

Statement of Understanding between AHA and HL7 can be found here. In particular see sections 4.1d and 4.2.

The UB-04 Manual has a 12-month subscription period from June 30 through July 1.

For frequently asked questions, see here here

This Code system is referenced in the content logical definition of the following value sets:

This CodeSystem is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

This code system https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit defines many codes, but they are not represented here

Indicates the type of .processNote for AEOB.

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

Codes indicating reasons why a claim or line item is adjusted.

Codes to specify the type of AEOB

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

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

Codes to specify the type of diagnosis

Financial Type codes for benefitBalance.financial.type.

CMS Place of Service codes

Defining codes for defining GFE request GFE contributor task status reason types.

These codes in this value set are derived from the NUBC Uniform Billing (UB-04) Type of Bill (TOB) codes. The fourth digit of the TOB code defines the frequency of the bill for the institutional and electronic professional claim.

Value Set containing codes for the type of adjudication information provided.

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

The FDA published list of NDC codes for finished drug products

NUBC UB-04 Revenue codes

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.

Defining codes for GFE Coordination Task status reason types.

Defining codes for defining GFE request types.

ICD-10 Codes to specify the type of diagnosis

Codes for the classification of organization contact purposes. This ValueSet is currently locally defined; an external FHIR value set may be created through the HL7 Terminology (THO) process to replace this value set in a future version.

Codes to specify the type of identifiers for organizations to indicate usage for a specific purpose. This ValueSet is currently locally defined; an external FHIR value set may be created through the HL7 Terminology (THO) process to replace this value set in a future version.

Codes to specify the type of entity involved in the PCT GFE process. This ValueSet is currently locally defined; an external FHIR value set may be created through the HL7 Terminology (THO) process to replace this value set in a future version.

Indicates the in network or out of network payment status of the claim or line item.

Indicates the Provider network status with the Payer as of the effective date of service or admission.

Codes to specify the type of procedure

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

Codes to specify the type of the supplied supporting information

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the Network Status.

Category codes for PCT benefitBalance.category from X12 service type.

Codes allowed for a GFE Contributor-specific service task status

US Claim Diagnosis Related Group Codes. All codes from MS-DRGs - AP-DRGs - APR-DRGs

Defining codes for process notes. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Codes indicating the type of adjudication information provided. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

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. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

PCT code system for defining the functional roles of the care team members. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for the classification of diagnosis types. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining the code for a estimate (GFE or AEOB) type summary. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Financial Type codes for benefitBalance.financial.type. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

These codes are derived from the NUBC Uniform Billing (UB-04) Type of Bill (TOB) codes. The fourth digit of the TOB code defines the frequency of the bill for the institutional and electronic professional claim. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for defining GFE request types. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for defining GFE request task status reason types. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for the classification of the supplied supporting information. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for types of identifiers. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for network status. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Organization Contact Purpose Type Code System. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Identifier Type codes for defining the type of identifier payers and providers assign to organizations. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for the classification of procedure types. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

Defining codes for the classification of subject-to-medical-management reason types. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

An instance of the PCTAdvancedEOB Profile

PCT AEOB Adjudication Error Example 1

PCT AEOB Bundle Example 1

PCT AEOB Complete Example 1

An instance of the PCTAdvancedEOBSummary Profile

PCT DeviceRequest Example 1

PCT GFE Bundle Institutional Example 1

PCT GFE Bundle Professional Example 1

PCT GFE Collection Bundle Example 1

PCT GFE Collection Bundle Example 1

PCT GFE Contributor Task example 1

PCT GFE Contributor Task example 2

PCT GFE Coordination Bundle Example 1

PCT GFE Coordination Task example 1

PCT GFE Information Bundle Example 1

PCT Institutional GFE Example 1

PCT Institutional GFE for MRI

PCT GFE Missing Bundle Example 1

PCT Professional GFE Example 1

PCT Summary GFE Example 1

PCT Summary GFE Example 1

PCT GFE Validation Error Example 1

PCT MedicationRequest Example 1

PCT ServiceLocation Example 1

PCT ServiceRequest Example 1

Institutional GFE Submitter 1

Professional GFE Submitter 1

An instance of Contract

An instance of PCTCoverage

An instance of Endpoint

An instance of PCTOrganization as a payer

An instance of PCTOrganization as a healthcare provider

An instance of Patient

An instance of PCTPractitioner

An instance of PCTPractitioner