PCT-AEOB-Bundle-1 - Patient Cost Transparency Implementation Guide v2.0.0-ballot

Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot United States of America flag

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

Example Bundle: PCT-AEOB-Bundle-1

Bundle PCT-AEOB-Bundle-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1

Resource ExplanationOfBenefit:

Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PCT-AEOB-Summary-1"
Profile: PCT Advanced EOB Summary
Service Description: Example service
In Network Provider Options Link: http://example.com/out-of-network.html
status: ACTIVE
type: Estimate Summary (PCT Estimate Type Code System#estimate-summary)
use: PREDETERMINATION
patient: See on this page: Patient/patient1001
billablePeriod: 2022-01-01 --> 2022-01-01
created: 2021-10-12
insurer: See on this page: Organization/org1001
provider: ??
outcome: COMPLETE
Insurances
- Focal Coverage
* true See on this page: Coverage/coverage1001
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency
* 200 USD
ProcessNotes
- Extension Text
* processNote disclaimer text
benefitPeriod: 2022-01-01 --> 2022-01-01
benefitBalance
category: Medical Care (X12 Service Type Codes#1)
unit: Individual (Unit Type Codes#individual)
term: Annual (Benefit Term Codes#annual)
Financials
- Extension Type Allowed[x] Used[x]
* Allowed (PCT Financial Type Code System#allowed) $1.00 (USD) $1.00 (USD)

Entry 2 - fullUrl = http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1

Resource ExplanationOfBenefit:

Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PCT-AEOB-1"
Profile: PCT Advanced EOB
GFE Reference: See on this page: Bundle/PCT-GFE-Bundle-Inst-1
Service Description: Example service
In Network Provider Options Link: http://example.com/out-of-network.html
identifier: Unique Claim ID/?ngen-9?
status: ACTIVE
type: Institutional (Claim Type Codes#institutional)
use: PREDETERMINATION
patient: See on this page: Patient/patient1001
created: 2021-10-12
insurer: See on this page: Organization/org1001
provider: Organization/org1002 "Boston Radiology Center"
priority: Normal (Process Priority Codes#normal)
claim: http://example.com/identifiers/bundle/59688475-2324-3242-23473847
outcome: COMPLETE
Insurances
- Focal Coverage
* true See on this page: Coverage/coverage1001
item
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
serviced: 2022-01-01
Nets
- Value Currency
* 200 USD
Adjudications
- Extension Category
* Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement)
Adjudications
- Extension Category
* Medical Management (PCT Adjudication Category CodeSystem#medicalmanagement)
* Submitted Amount (Adjudication Value Codes#submitted)
* Member Liability (PCT Adjudication Category CodeSystem#memberliability)
total
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
- Value Currency
* 200 USD
ProcessNotes
- Extension Text
* processNote disclaimer text
benefitPeriod: 2022-01-01 --> 2023-01-01
benefitBalance
category: Medical Care (X12 Service Type Codes#1)
unit: Individual (Unit Type Codes#individual)
term: Annual (Benefit Term Codes#annual)
Financials
- Extension Type Allowed[x] Used[x]
* Allowed (PCT Financial Type Code System#allowed) $1.00 (USD) $1.00 (USD)

Entry 3 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

Eve Betterhalf female, DoB: 1955-07-23 ( http://example.com/identifiers/patient/1001)
Marital Status: unmarried
Contact Details:
ph: 781-949-4949(MOBILE)
222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)

Entry 4 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

Resource Coverage "coverage1001"
Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: active
subscriberId: PFP123450000
beneficiary: Patient/patient1001 " BETTERHALF"
relationship: Self (SubscriberPolicyholder Relationship Codes#self)
period: 2021-01-01 --> 2022-01-01
payor: Organization/org1001 "Umbrella Insurance Company"
Classes
- Type Value Name
* Plan (Coverage Class Codes#plan) Premim Family Plus Premim Family Plus Plan
CostToBeneficiaries
- Type Value[x]
* Copay Percentage (Coverage Copay Type Codes#copaypct) 20

Entry 5 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

Resource Organization "org1001"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer (Organization type#pay)
name: Umbrella Insurance Company
telecom: ph: 860-547-5001(WORK)
address: 680 Asylum Street Hartford CT 06155 US

Entry 6 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1

Resource Bundle:

Bundle PCT-GFE-Bundle-Inst-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-1
Resource Claim:
Resource Claim "PCT-GFE-Summary-1"
Profile: PCT Good Faith Estimate Summary
status: active
type: Estimate Summary (PCT Estimate Type Code System#estimate-summary)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
billablePeriod: 2021-10-31 --> 2021-10-31
created: 2021-10-05
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: ??
priority: Normal (Process Priority Codes#normal)
Diagnoses
- Sequence Diagnosis[x] Type PackageCode
* 1 Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30) Principal Diagnosis (Example Diagnosis Type Codes#principal) Head trauma - concussion (Example Diagnosis Related Group Codes#400)
Insurances
- Sequence Focal Coverage
* 1 true Coverage/coverage1001
Totals
- Value Currency
* 200 USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Institutional-1
Resource Claim:
Resource Claim "PCT-GFE-Institutional-1"
Profile: PCT Good Faith Estimate Institutional
ProviderEventMethodology: EEMM1021
GFEDisclaimer: For estimation purposes only
GFEServiceLinkingInfo
url
linkingIdentifier
value: 223452-2342-2435-008001
url
plannedPeriodOfService
value: 2021-10-31
identifier: Placer Identifier/GFEProviderAssignedID0001
status: active
type: Institutional (Claim Type Codes#institutional)
use: predetermination
patient: Patient/patient1001 " BETTERHALF"
created: 2021-10-05
insurer: Organization/org1001 "Umbrella Insurance Company"
provider: Organization/Submitter-Org-1 "GFE Service Help INC."
priority: Normal (Process Priority Codes#normal)
Payees
- Type
* Provider (Payee Type Codes#provider)
referral: : Referral Number
SupportingInfos
- Sequence Category Code
* 1 Type of Bill (PCT GFE Supporting Info Type Code System#typeofbill) Hospital Inpatient (Part A) (AHA NUBC Type Of Bill Codes#011X)
Diagnoses
- Sequence Diagnosis[x] Type PackageCode
* 1 Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30) Principal Diagnosis (Example Diagnosis Type Codes#principal) Head trauma - concussion (Example Diagnosis Related Group Codes#400)
Insurances
- Sequence Focal Coverage
* 1 true Coverage/coverage1001
item
Service Description: Imaging
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem (AHA NUBC Revenue Codes#0611)
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material (Current Procedural Terminology (CPT®)#70551)
serviced: 2021-10-31
quantity: 1
Nets
- Value Currency
* 200 USD
Totals
- Value Currency
* 200 USD

Entry 3 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1
Resource Organization:
Resource Organization "Submitter-Org-1"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-10010301
active: true
type: Non-Healthcare Business or Corporation (Organization type#bus)
name: GFE Service Help INC.
Contacts
- Purpose Name Telecom
* GFE-related (PCT Organization Contact Purpose Type Code System#GFERELATED) Clara Sender ph: 781-632-3209(WORK), csender@GFEServiceHelp.com

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:
Resource Organization "org1001"
Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer (Organization type#pay)
name: Umbrella Insurance Company
telecom: ph: 860-547-5001(WORK)
address: 680 Asylum Street Hartford CT 06155 US

Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf female, DoB: 1955-07-23 ( http://example.com/identifiers/patient/1001)
Marital Status: unmarried
Contact Details:
ph: 781-949-4949(MOBILE)
222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)

Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:
Resource Coverage "coverage1001"
Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: active
subscriberId: PFP123450000
beneficiary: Patient/patient1001 " BETTERHALF"
relationship: Self (SubscriberPolicyholder Relationship Codes#self)
period: 2021-01-01 --> 2022-01-01
payor: Organization/org1001 "Umbrella Insurance Company"
Classes
- Type Value Name
* Plan (Coverage Class Codes#plan) Premim Family Plus Premim Family Plus Plan
CostToBeneficiaries
- Type Value[x]
* Copay Percentage (Coverage Copay Type Codes#copaypct) 20

IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-08
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