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

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 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-Packet-1

Document Details

Profile: PCT AEOB Packet

Final Document at 2025-01-10 11:01:00+0500 by Organization Umbrella Insurance Company, Organization GFE Service Help INC. for Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

Document Subject

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)

Document Content

AEOB Summary

Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1

Profile: PCT Advanced EOB Summary

Service Description: Example service

In Network Provider Options Link: http://example.org/out-of-network.html

status: Active

type: Estimate Summary

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

billablePeriod: 2022-01-01 --> 2022-01-01

created: 2021-10-12

insurer: Organization Umbrella Insurance Company

provider: ?rref?

outcome: Processing Complete

Insurances

Focal

Coverage

true

Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

total
category: Submitted Amount
Amounts
- Value Currency
* 200 United States dollar

total
category: Member liability
Amounts
- Value Currency
* 20 United States dollar

total
category: Eligible Amount
Amounts
- Value Currency
* 190 United States dollar

ProcessNotes

Extension

Text

processNote disclaimer text

benefitPeriod: 2022-01-01 --> 2022-01-01

benefitBalance
category: Medical Care
unit: Individual
term: Annual
Financials
- Extension Type Allowed[x] Used[x]
* Allowed $1.00 (USD) $1.00 (USD)

AEOB Section

Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1

Profile: PCT Advanced EOB Summary

Service Description: Example service

In Network Provider Options Link: http://example.org/out-of-network.html

status: Active

type: Estimate Summary

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

billablePeriod: 2022-01-01 --> 2022-01-01

created: 2021-10-12

insurer: Organization Umbrella Insurance Company

provider: ?rref?

outcome: Processing Complete

Insurances

Focal

Coverage

true

Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

total
category: Submitted Amount
Amounts
- Value Currency
* 200 United States dollar

total
category: Member liability
Amounts
- Value Currency
* 20 United States dollar

total
category: Eligible Amount
Amounts
- Value Currency
* 190 United States dollar

ProcessNotes

Extension

Text

processNote disclaimer text

benefitPeriod: 2022-01-01 --> 2022-01-01

benefitBalance
category: Medical Care
unit: Individual
term: Annual
Financials
- Extension Type Allowed[x] Used[x]
* Allowed $1.00 (USD) $1.00 (USD)

GFE Section

Generated Narrative: PCT-GFE-Missing-Bundle-1

patient: Eve Betterhalf Female, DoB: 1955-07-23 (http://example.com/identifiers/patient#1001)

coverage: Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01

organization: Umbrella Insurance Company

Requested Services

device request: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

GFE Section

Additional Resources Included in Document

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

Resource ExplanationOfBenefit:

Profile: PCT Advanced EOB Summary
Service Description: Example service
In Network Provider Options Link: http://example.org/out-of-network.html
status: Active
type: Estimate Summary
use: Predetermination
patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
billablePeriod: 2022-01-01 --> 2022-01-01
created: 2021-10-12
insurer: Organization Umbrella Insurance Company
provider: ?rref?
outcome: complete
Insurances
- Focal Coverage
* true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01
total
category: Submitted Amount
Amounts
- Value Currency
* 200 USD
total
category: Member liability
Amounts
- Value Currency
* 20 USD
total
category: Eligible Amount
Amounts
- Value Currency
* 190 USD
ProcessNotes
- Extension Text
* processNote disclaimer text
benefitPeriod: 2022-01-01 --> 2022-01-01
benefitBalance
category: Medical Care
unit: Individual
term: Annual
Financials
- Extension Type Allowed[x] Used[x]
* Allowed $1.00 (USD) $1.00 (USD)

Entry 3 - fullUrl = http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1

Resource ExplanationOfBenefit:

Profile: PCT Advanced EOB
GFE Reference: Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-23473847; type = collection; timestamp = 2021-11-09 11:01:00+0500
Service Description: Example service
In Network Provider Options Link: http://example.org/out-of-network.html
identifier: Unique Claim Identifier/?ngen-9?
status: Active
type: Institutional
use: Predetermination
patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
created: 2021-10-12
insurer: Organization Umbrella Insurance Company
provider: Organization Boston Radiology Center
priority: Normal
claim: Identifier: http://example.com/identifiers/bundle/59688475-2324-3242-23473847
outcome: complete
Insurances
- Focal Coverage
* true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01
item
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
serviced: 2022-01-01
Nets
- Value Currency
* 200 USD
Adjudications
- Extension Category
* Medical Management
Adjudications
- Extension Category
* Medical Management
* Submitted Amount
* Member Liability
total
category: Submitted Amount
Amounts
- Value Currency
* 200 USD
total
category: Member liability
Amounts
- Value Currency
* 20 USD
total
category: Eligible Amount
Amounts
- Value Currency
* 190 USD
ProcessNotes
- Extension Text
* processNote disclaimer text
benefitPeriod: 2022-01-01 --> 2023-01-01
benefitBalance
category: Medical Care
unit: Individual
term: Annual
Financials
- Extension Type Allowed[x] Used[x]
* Allowed $1.00 (USD) $1.00 (USD)

Entry 4 - 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 5 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: Active
subscriberId: PFP123450000
beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
relationship: Self
period: 2021-01-01 --> 2022-01-01
Classes
- Type Value Name
* Plan Premim Family Plus Premim Family Plus Plan
CostToBeneficiaries
- Type Value[x]
* Copay Percentage 20

Entry 6 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer
name: Umbrella Insurance Company
Contacts
- Telecom Address
* ph: 860-547-5001(Work) 680 Asylum Street Hartford CT 06155 US

Entry 7 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1

Resource Organization:

Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-10010301
active: true
type: Non-Healthcare Business or Corporation
name: GFE Service Help INC.
contact
purpose: GFE-related
name: Clara Sender
telecom: ph: 781-632-3209(Work), csender@GFEServiceHelp.com

Entry 8 - fullUrl = http://example.org/fhir/Organization/org1002

Resource Organization:

Profile: PCT Organization
identifier: United States National Provider Identifier/9941339100, Tax ID number/TAX-3211001
active: true
type: Healthcare Provider
name: Boston Radiology Center
Contacts
- Telecom Address
* ph: 781-232-3200(Work) 32 Fruit Street Boston MA 02114 US

Entry 9 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1

Resource Bundle:

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

Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-1
Resource Claim:

Profile: PCT Good Faith Estimate Summary
status: Active
type: Estimate Summary
use: Predetermination
patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
billablePeriod: 2021-10-31 --> 2021-10-31
created: 2021-10-05
insurer: Organization Umbrella Insurance Company
provider: ?rref?
priority: Normal
Diagnoses
- Sequence Diagnosis[x] Type
* 1 Unspecified focal traumatic brain injury Principal Diagnosis
Insurances
- Sequence Focal Coverage
* 1 true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01
Totals
- Value Currency
* 200 USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Institutional-1
Resource Claim:

Profile: PCT Good Faith Estimate Institutional
ProviderEventMethodology: EEMM1021
GFEDisclaimer: For estimation purposes only
GFEServiceLinkingInfo
linkingIdentifier: http://example.org/Claim/identifiers/223452-2342-2435-008001
plannedPeriodOfService: 2021-10-31
identifier: Placer Identifier/GFEProviderAssignedID0001
status: Active
type: Institutional
use: Predetermination
patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
created: 2021-10-05
insurer: Organization Umbrella Insurance Company
provider: Organization GFE Service Help INC.
priority: Normal
Payees
- Type
* Provider
referral: Referral Number
SupportingInfos
- Sequence Category Code
* 1 Type of Bill Hospital Inpatient (Part A)
Diagnoses
- Sequence Diagnosis[x] Type
* 1 Unspecified focal traumatic brain injury Principal Diagnosis
Insurances
- Sequence Focal Coverage
* 1 true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01
item
Service Description: Imaging
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
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:

Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-10010301
active: true
type: Non-Healthcare Business or Corporation
name: GFE Service Help INC.
contact
purpose: GFE-related
name: Clara Sender
telecom: ph: 781-632-3209(Work), csender@GFEServiceHelp.com

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:

Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer
name: Umbrella Insurance Company
Contacts
- Telecom Address
* ph: 860-547-5001(Work) 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:

Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: Active
subscriberId: PFP123450000
beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
relationship: Self
period: 2021-01-01 --> 2022-01-01
Classes
- Type Value Name
* Plan Premim Family Plus Premim Family Plus Plan
CostToBeneficiaries
- Type Value[x]
* Copay Percentage 20

Entry 10 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1

Resource Bundle:

Profile: PCT GFE Missing Bundle
Bundle PCT-GFE-Missing-Bundle-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Organization/org1002
Resource Organization:

Profile: PCT Organization
identifier: United States National Provider Identifier/9941339100, Tax ID number/TAX-3211001
active: true
type: Healthcare Provider
name: Boston Radiology Center
Contacts
- Telecom Address
* ph: 781-232-3200(Work) 32 Fruit Street Boston MA 02114 US

Entry 2 - 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 3 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:

Profile: PCT Coverage
Extension Definition for Coverage.kind for Version 5.0: insurance
status: Active
subscriberId: PFP123450000
beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
relationship: Self
period: 2021-01-01 --> 2022-01-01
Classes
- Type Value Name
* Plan Premim Family Plus Premim Family Plus Plan
CostToBeneficiaries
- Type Value[x]
* Copay Percentage 20

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:

Profile: PCT Organization
identifier: Electronic Transmitter Identification Number/ETIN-3200002
active: true
type: Payer
name: Umbrella Insurance Company
Contacts
- Telecom Address
* ph: 860-547-5001(Work) 680 Asylum Street Hartford CT 06155 US

Entry 5 - fullUrl = http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1
Resource DeviceRequest:

Profile: PCT GFE DeviceRequest
status: Active
intent: Proposal
subject: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)