Patient Cost Transparency Implementation Guide
2.0.0 - STU 2
Patient Cost Transparency Implementation Guide
2.0.0 - STU 2
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
{
"resourceType" : "Bundle",
"id" : "PCT-AEOB-Packet-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-packet"
]
},
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-1234568"
},
"type" : "document",
"timestamp" : "2025-01-10T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Composition/PCT-AEOB-Composition-1",
"resource" : {
"resourceType" : "Composition",
"id" : "PCT-AEOB-Composition-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-composition"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_PCT-AEOB-Composition-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Composition PCT-AEOB-Composition-1</b></p><a name=\"PCT-AEOB-Composition-1\"> </a><a name=\"hcPCT-AEOB-Composition-1\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob-composition.html\">PCT AEOB Composition</a></p></div><p><b>Request Initiation Time</b>: 2025-01-08 09:01:00+0500</p><p><b>identifier</b>: <code>http://www.example.org/identifiers/composition</code>/019283475</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 111479-2}\">Advanced explanation of benefits</span></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse estimate}\">Estimation Packet</span></p><p><b>date</b>: 2025-01-10 11:01:00+0500</p><p><b>author</b>: </p><ul><li><a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></li><li><a href=\"Organization-Submitter-Org-1.html\">Organization GFE Service Help INC.</a></li></ul><p><b>title</b>: Advanced Explanation of Benefit Packet for Eve Betterhalf - 2025-01-10</p></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestInitiationTime",
"valueInstant" : "2025-01-08T09:01:00+05:00"
}
],
"identifier" : {
"system" : "http://www.example.org/identifiers/composition",
"value" : "019283475"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "111479-2",
"display" : "Advanced explanation of benefits"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse",
"code" : "estimate"
}
]
}
],
"subject" : {
🔗 "reference" : "Patient/patient1001"
},
"date" : "2025-01-10T11:01:00+05:00",
"author" : [
{
🔗 "reference" : "Organization/org1001"
},
{
🔗 "reference" : "Organization/Submitter-Org-1"
}
],
"title" : "Advanced Explanation of Benefit Packet for Eve Betterhalf - 2025-01-10",
"section" : [
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code" : "aeob-summary-section"
}
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob-summary.html\">PCT Advanced EOB Summary</a></p></div><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href=\"http://example.org/out-of-network.html\">http://example.org/out-of-network.html</a></p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</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>billablePeriod</b>: 2022-01-01 --> 2022-01-01</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>: ?rref?</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; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01</a></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><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member liability</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>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible 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>190</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 --> 2022-01-01</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>"
},
"entry" : [
{
🔗 "reference" : "ExplanationOfBenefit/PCT-AEOB-Summary-1"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code" : "aeob-section"
}
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1</b></p><a name=\"PCT-AEOB-Summary-1\"/><a name=\"hcPCT-AEOB-Summary-1\"/><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob-summary.html\">PCT Advanced EOB Summary</a></p></div><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href=\"http://example.org/out-of-network.html\">http://example.org/out-of-network.html</a></p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</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>billablePeriod</b>: 2022-01-01 --> 2022-01-01</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>: ?rref?</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; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01</a></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><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member liability</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>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible 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>190</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 --> 2022-01-01</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>"
},
"entry" : [
{
🔗 "reference" : "ExplanationOfBenefit/PCT-AEOB-1"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code" : "gfe-section"
}
]
},
"author" : [
{
🔗 "reference" : "Organization/Submitter-Org-1"
}
],
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: PCT-GFE-Missing-Bundle-1</b></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>coverage</b>: <a href=\"Patient-patient1001.html\">Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01</a></p><p><b>organization</b>: <a href=\"Organization-org1001.html\">Umbrella Insurance Company</a></p><h3>Requested Services</h3><ul><li><b>device request</b>: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT</li></ul></div>"
},
"entry" : [
{
🔗 "reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection",
"code" : "gfe-section"
}
]
},
"author" : [
{
🔗 "reference" : "Organization/Submitter-Org-1"
}
],
"entry" : [
{
🔗 "reference" : "Bundle/PCT-GFE-Missing-Bundle-1"
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1",
"resource" : {
"resourceType" : "ExplanationOfBenefit",
"id" : "PCT-AEOB-Summary-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ExplanationOfBenefit_PCT-AEOB-Summary-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1</b></p><a name=\"PCT-AEOB-Summary-1\"> </a><a name=\"hcPCT-AEOB-Summary-1\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob-summary.html\">PCT Advanced EOB Summary</a></p></div><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href=\"http://example.org/out-of-network.html\">http://example.org/out-of-network.html</a></p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</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>billablePeriod</b>: 2022-01-01 --> 2022-01-01</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>: ?rref?</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; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01</a></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><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member liability</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>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible 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>190</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 --> 2022-01-01</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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString" : "Example service"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
"valueUrl" : "http://example.org/out-of-network.html"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
"code" : "estimate-summary",
"display" : "Estimate Summary"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/patient1001"
},
"billablePeriod" : {
"start" : "2022-01-01",
"end" : "2022-01-01"
},
"created" : "2021-10-12",
"insurer" : {
🔗 "reference" : "Organization/org1001"
},
"provider" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode" : "not-applicable"
}
]
},
"outcome" : "complete",
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/coverage1001"
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"version" : "1.0.1",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "memberliability",
"display" : "Member liability"
}
]
},
"amount" : {
"value" : 20,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"version" : "1.0.1",
"code" : "eligible",
"display" : "Eligible Amount"
}
]
},
"amount" : {
"value" : 190,
"currency" : "USD"
}
}
],
"processNote" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
"code" : "disclaimer",
"display" : "Disclaimer"
}
]
}
}
],
"text" : "processNote disclaimer text"
}
],
"benefitPeriod" : {
"start" : "2022-01-01",
"end" : "2022-01-01"
},
"benefitBalance" : [
{
"category" : {
"coding" : [
{
"system" : "https://x12.org/codes/service-type-codes",
"code" : "1",
"display" : "Medical Care"
}
],
"text" : "Medical Care"
},
"unit" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
"code" : "individual"
}
]
},
"term" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
"code" : "annual"
}
]
},
"financial" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
"valueMoney" : {
"value" : 0,
"currency" : "USD"
}
}
],
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"code" : "allowed"
}
]
},
"allowedMoney" : {
"value" : 1,
"currency" : "USD"
},
"usedMoney" : {
"value" : 1,
"currency" : "USD"
}
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1",
"resource" : {
"resourceType" : "ExplanationOfBenefit",
"id" : "PCT-AEOB-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ExplanationOfBenefit_PCT-AEOB-1\"> </a><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><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-aeob.html\">PCT Advanced EOB</a></p></div><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.org/out-of-network.html\">http://example.org/out-of-network.html</a></p><p><b>identifier</b>: Unique Claim Identifier/?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; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 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><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member liability</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>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible 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>190</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 --> 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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
"valueReference" : {
🔗 "reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString" : "Example service"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
"valueUrl" : "http://example.org/out-of-network.html"
}
],
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "UCID"
}
]
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional",
"display" : "Institutional"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/patient1001"
},
"created" : "2021-10-12",
"insurer" : {
🔗 "reference" : "Organization/org1001"
},
"provider" : {
🔗 "reference" : "Organization/org1002"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"claim" : {
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-23473847"
}
},
"outcome" : "complete",
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/coverage1001"
}
}
],
"item" : [
{
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0611",
"display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "70551",
"display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
}
]
},
"modifier" : [
{
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "70551",
"display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
}
]
}
],
"servicedDate" : "2022-01-01",
"net" : {
"value" : 200,
"currency" : "USD"
},
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/medical-management-type",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "medicalmanagement",
"display" : "Medical Management"
}
]
}
}
]
}
],
"adjudication" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/medical-management-type",
"code" : "concurrent-review",
"display" : "Concurrent Review"
}
]
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "medicalmanagement",
"display" : "Medical Management"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "memberliability",
"display" : "Member Liability"
}
]
}
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"version" : "1.0.1",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 200,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
"code" : "memberliability",
"display" : "Member liability"
}
]
},
"amount" : {
"value" : 20,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"version" : "1.0.1",
"code" : "eligible",
"display" : "Eligible Amount"
}
]
},
"amount" : {
"value" : 190,
"currency" : "USD"
}
}
],
"processNote" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
"code" : "disclaimer",
"display" : "Disclaimer"
}
]
}
}
],
"text" : "processNote disclaimer text"
}
],
"benefitPeriod" : {
"start" : "2022-01-01",
"end" : "2023-01-01"
},
"benefitBalance" : [
{
"category" : {
"coding" : [
{
"system" : "https://x12.org/codes/service-type-codes",
"code" : "1",
"display" : "Medical Care"
}
],
"text" : "Medical Care"
},
"unit" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
"code" : "individual"
}
]
},
"term" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
"code" : "annual"
}
]
},
"financial" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
"valueMoney" : {
"value" : 0,
"currency" : "USD"
}
}
],
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"code" : "allowed"
}
]
},
"allowedMoney" : {
"value" : 1,
"currency" : "USD"
},
"usedMoney" : {
"value" : 1,
"currency" : "USD"
}
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/patient1001",
"resource" : {
"resourceType" : "Patient",
"id" : "patient1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"
]
},
"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_patient1001\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}\">unmarried</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Languages spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes: {urn:ietf:bcp:47 en-US}\">English (United States)</span> (preferred)</td></tr></table></div>"
},
"identifier" : [
{
"system" : "http://example.com/identifiers/patient",
"value" : "1001"
}
],
"name" : [
{
"text" : "Eve Betterhalf",
"family" : "Betterhalf",
"given" : [
"Eve"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "781-949-4949",
"use" : "mobile"
}
],
"gender" : "female",
"birthDate" : "1955-07-23",
"address" : [
{
"text" : "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code" : "U",
"display" : "unmarried"
}
]
},
"communication" : [
{
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en-US",
"display" : "English (United States)"
}
]
},
"preferred" : true
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/coverage1001",
"resource" : {
"resourceType" : "Coverage",
"id" : "coverage1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_coverage1001\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage coverage1001</b></p><a name=\"coverage1001\"> </a><a name=\"hccoverage1001\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-coverage.html\">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: Active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><h3>Classes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\">Plan</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type copaypct}\">Copay Percentage</span></td><td>20</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind",
"valueCode" : "insurance"
}
],
"status" : "active",
"subscriberId" : "PFP123450000",
"beneficiary" : {
🔗 "reference" : "Patient/patient1001"
},
"relationship" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code" : "self",
"display" : "Self"
}
]
},
"period" : {
"start" : "2021-01-01",
"end" : "2022-01-01"
},
"payor" : [
{
🔗 "reference" : "Organization/org1001"
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "plan",
"display" : "Plan"
}
]
},
"value" : "Premim Family Plus",
"name" : "Premim Family Plus Plan"
}
],
"costToBeneficiary" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "copaypct",
"display" : "Copay Percentage"
}
]
},
"valueQuantity" : {
"value" : 20
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/org1001",
"resource" : {
"resourceType" : "Organization",
"id" : "org1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_org1001\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization org1001</b></p><a name=\"org1001\"> </a><a name=\"hcorg1001\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-organization.html\">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type pay}\">Payer</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(Work)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US </p></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "ETIN"
}
]
},
"value" : "ETIN-3200002"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "pay",
"display" : "Payer"
}
]
}
],
"name" : "Umbrella Insurance Company",
"telecom" : [
{
"system" : "phone",
"value" : "860-547-5001",
"use" : "work"
}
],
"address" : [
{
"line" : [
"680 Asylum Street"
],
"city" : "Hartford",
"state" : "CT",
"postalCode" : "06155",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/Submitter-Org-1",
"resource" : {
"resourceType" : "Organization",
"id" : "Submitter-Org-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_Submitter-Org-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization Submitter-Org-1</b></p><a name=\"Submitter-Org-1\"> </a><a name=\"hcSubmitter-Org-1\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-organization.html\">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-10010301</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type bus}\">Non-Healthcare Business or Corporation</span></p><p><b>name</b>: GFE Service Help INC.</p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType GFERELATED}\">GFE-related</span></p><p><b>name</b>: Clara Sender</p><p><b>telecom</b>: ph: 781-632-3209(Work), <a href=\"mailto:csender@GFEServiceHelp.com\">csender@GFEServiceHelp.com</a></p></blockquote></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "ETIN"
}
]
},
"value" : "ETIN-10010301"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "bus"
}
]
}
],
"name" : "GFE Service Help INC.",
"contact" : [
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType",
"code" : "GFERELATED"
}
]
},
"name" : {
"text" : "Clara Sender"
},
"telecom" : [
{
"system" : "phone",
"value" : "781-632-3209",
"use" : "work"
},
{
"system" : "email",
"value" : "csender@GFEServiceHelp.com",
"use" : "work"
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/org1002",
"resource" : {
"resourceType" : "Organization",
"id" : "org1002",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_org1002\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization org1002</b></p><a name=\"org1002\"> </a><a name=\"hcorg1002\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-organization.html\">PCT Organization</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/6.5.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/9941339100, Tax ID number/TAX-3211001</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span></p><p><b>name</b>: Boston Radiology Center</p><p><b>telecom</b>: ph: 781-232-3200(Work)</p><p><b>address</b>: 32 Fruit Street Boston MA 02114 US </p></div>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "9941339100"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "TAX"
}
]
},
"system" : "urn:oid:2.16.840.1.113883.4.4",
"value" : "TAX-3211001"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "prov",
"display" : "Healthcare Provider"
}
]
}
],
"name" : "Boston Radiology Center",
"telecom" : [
{
"system" : "phone",
"value" : "781-232-3200",
"use" : "work"
}
],
"address" : [
{
"line" : [
"32 Fruit Street"
],
"city" : "Boston",
"state" : "MA",
"postalCode" : "02114",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1",
"resource" : {
"resourceType" : "Bundle",
"id" : "PCT-GFE-Bundle-Inst-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"
]
},
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-23473847"
},
"type" : "collection",
"timestamp" : "2021-11-09T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Summary-1",
"resource" : {
"resourceType" : "Claim",
"id" : "PCT-GFE-Summary-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"
]
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
"code" : "estimate-summary",
"display" : "Estimate Summary"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/patient1001"
},
"billablePeriod" : {
"start" : "2021-10-31",
"end" : "2021-10-31"
},
"created" : "2021-10-05",
"insurer" : {
🔗 "reference" : "Organization/org1001"
},
"provider" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode" : "not-applicable"
}
]
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "S06.30",
"display" : "Unspecified focal traumatic brain injury"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/diagnosistype",
"code" : "principal"
}
]
}
],
"packageCode" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
"code" : "400",
"display" : "Head trauma - concussion"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/coverage1001"
}
}
],
"total" : {
"value" : 200,
"currency" : "USD"
}
}
},
{
"fullUrl" : "http://example.org/fhir/Claim/PCT-GFE-Institutional-1",
"resource" : {
"resourceType" : "Claim",
"id" : "PCT-GFE-Institutional-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"
]
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
"valueString" : "EEMM1021"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer",
"valueString" : "For estimation purposes only"
},
{
"extension" : [
{
"url" : "linkingIdentifier",
"valueIdentifier" : {
"system" : "http://example.org/Claim/identifiers",
"value" : "223452-2342-2435-008001"
}
},
{
"url" : "plannedPeriodOfService",
"valueDate" : "2021-10-31"
}
],
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
}
],
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "PLAC",
"display" : "Placer Identifier"
}
]
},
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"value" : "GFEProviderAssignedID0001"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional",
"display" : "Institutional"
}
]
},
"use" : "predetermination",
"patient" : {
🔗 "reference" : "Patient/patient1001"
},
"created" : "2021-10-05",
"insurer" : {
🔗 "reference" : "Organization/org1001"
},
"provider" : {
🔗 "extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://nucc.org/provider-taxonomy",
"code" : "2085D0003X",
"display" : "Diagnostic Neuroimaging (Radiology) Physician"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling",
"valueBoolean" : true
}
],
"reference" : "Organization/Submitter-Org-1"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"payee" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
}
},
"referral" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber",
"valueString" : "REF12022002-121"
}
],
"display" : "Referral Number"
},
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType",
"code" : "typeofbill"
}
]
},
"code" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/TypeOfBill",
"code" : "011X",
"display" : "Hospital Inpatient (Part A)"
}
]
}
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "S06.30",
"display" : "Unspecified focal traumatic brain injury"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/diagnosistype",
"code" : "principal"
}
]
}
],
"packageCode" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
"code" : "400",
"display" : "Head trauma - concussion"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/coverage1001"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
"valueString" : "Imaging"
}
],
"sequence" : 1,
"revenue" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0611",
"display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "70551",
"display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
}
]
},
"modifier" : [
{
"coding" : [
{
"system" : "http://www.ama-assn.org/go/cpt",
"code" : "70551",
"display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
}
]
}
],
"servicedDate" : "2021-10-31",
"quantity" : {
"value" : 1
},
"net" : {
"value" : 200,
"currency" : "USD"
}
}
],
"total" : {
"value" : 200,
"currency" : "USD"
}
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/Submitter-Org-1",
"resource" : {
"resourceType" : "Organization",
"id" : "Submitter-Org-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "ETIN"
}
]
},
"value" : "ETIN-10010301"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "bus"
}
]
}
],
"name" : "GFE Service Help INC.",
"contact" : [
{
"purpose" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType",
"code" : "GFERELATED"
}
]
},
"name" : {
"text" : "Clara Sender"
},
"telecom" : [
{
"system" : "phone",
"value" : "781-632-3209",
"use" : "work"
},
{
"system" : "email",
"value" : "csender@GFEServiceHelp.com",
"use" : "work"
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/org1001",
"resource" : {
"resourceType" : "Organization",
"id" : "org1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "ETIN"
}
]
},
"value" : "ETIN-3200002"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "pay",
"display" : "Payer"
}
]
}
],
"name" : "Umbrella Insurance Company",
"telecom" : [
{
"system" : "phone",
"value" : "860-547-5001",
"use" : "work"
}
],
"address" : [
{
"line" : [
"680 Asylum Street"
],
"city" : "Hartford",
"state" : "CT",
"postalCode" : "06155",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/patient1001",
"resource" : {
"resourceType" : "Patient",
"id" : "patient1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"
]
},
"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}\">unmarried</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Languages spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes: {urn:ietf:bcp:47 en-US}\">English (United States)</span> (preferred)</td></tr></table></div>"
},
"identifier" : [
{
"system" : "http://example.com/identifiers/patient",
"value" : "1001"
}
],
"name" : [
{
"text" : "Eve Betterhalf",
"family" : "Betterhalf",
"given" : [
"Eve"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "781-949-4949",
"use" : "mobile"
}
],
"gender" : "female",
"birthDate" : "1955-07-23",
"address" : [
{
"text" : "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code" : "U",
"display" : "unmarried"
}
]
},
"communication" : [
{
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en-US",
"display" : "English (United States)"
}
]
},
"preferred" : true
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/coverage1001",
"resource" : {
"resourceType" : "Coverage",
"id" : "coverage1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"extension" : [
{
"url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind",
"valueCode" : "insurance"
}
],
"status" : "active",
"subscriberId" : "PFP123450000",
"beneficiary" : {
🔗 "reference" : "Patient/patient1001"
},
"relationship" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code" : "self",
"display" : "Self"
}
]
},
"period" : {
"start" : "2021-01-01",
"end" : "2022-01-01"
},
"payor" : [
{
🔗 "reference" : "Organization/org1001"
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "plan",
"display" : "Plan"
}
]
},
"value" : "Premim Family Plus",
"name" : "Premim Family Plus Plan"
}
],
"costToBeneficiary" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "copaypct",
"display" : "Copay Percentage"
}
]
},
"valueQuantity" : {
"value" : 20
}
}
]
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1",
"resource" : {
"resourceType" : "Bundle",
"id" : "PCT-GFE-Missing-Bundle-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle"
]
},
"identifier" : {
"system" : "http://example.com/identifiers/bundle",
"value" : "59688475-2324-3242-2347384376"
},
"type" : "collection",
"timestamp" : "2024-03-27T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Organization/org1002",
"resource" : {
"resourceType" : "Organization",
"id" : "org1002",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "9941339100"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "TAX"
}
]
},
"system" : "urn:oid:2.16.840.1.113883.4.4",
"value" : "TAX-3211001"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "prov",
"display" : "Healthcare Provider"
}
]
}
],
"name" : "Boston Radiology Center",
"telecom" : [
{
"system" : "phone",
"value" : "781-232-3200",
"use" : "work"
}
],
"address" : [
{
"line" : [
"32 Fruit Street"
],
"city" : "Boston",
"state" : "MA",
"postalCode" : "02114",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/patient1001",
"resource" : {
"resourceType" : "Patient",
"id" : "patient1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"
]
},
"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Known Marital status of Patient\">Marital Status:</td><td colspan=\"3\"><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}\">unmarried</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Details:</td><td colspan=\"3\"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Languages spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes: {urn:ietf:bcp:47 en-US}\">English (United States)</span> (preferred)</td></tr></table></div>"
},
"identifier" : [
{
"system" : "http://example.com/identifiers/patient",
"value" : "1001"
}
],
"name" : [
{
"text" : "Eve Betterhalf",
"family" : "Betterhalf",
"given" : [
"Eve"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "781-949-4949",
"use" : "mobile"
}
],
"gender" : "female",
"birthDate" : "1955-07-23",
"address" : [
{
"text" : "222 Burlington Road, Bedford MA 01730"
}
],
"maritalStatus" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code" : "U",
"display" : "unmarried"
}
]
},
"communication" : [
{
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en-US",
"display" : "English (United States)"
}
]
},
"preferred" : true
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/coverage1001",
"resource" : {
"resourceType" : "Coverage",
"id" : "coverage1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
]
},
"extension" : [
{
"url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind",
"valueCode" : "insurance"
}
],
"status" : "active",
"subscriberId" : "PFP123450000",
"beneficiary" : {
🔗 "reference" : "Patient/patient1001"
},
"relationship" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code" : "self",
"display" : "Self"
}
]
},
"period" : {
"start" : "2021-01-01",
"end" : "2022-01-01"
},
"payor" : [
{
🔗 "reference" : "Organization/org1001"
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "plan",
"display" : "Plan"
}
]
},
"value" : "Premim Family Plus",
"name" : "Premim Family Plus Plan"
}
],
"costToBeneficiary" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
"code" : "copaypct",
"display" : "Copay Percentage"
}
]
},
"valueQuantity" : {
"value" : 20
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/org1001",
"resource" : {
"resourceType" : "Organization",
"id" : "org1001",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"
]
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "ETIN"
}
]
},
"value" : "ETIN-3200002"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "pay",
"display" : "Payer"
}
]
}
],
"name" : "Umbrella Insurance Company",
"telecom" : [
{
"system" : "phone",
"value" : "860-547-5001",
"use" : "work"
}
],
"address" : [
{
"line" : [
"680 Asylum Street"
],
"city" : "Hartford",
"state" : "CT",
"postalCode" : "06155",
"country" : "US"
}
]
}
},
{
"id" : "PCT-DeviceRequest-1",
"fullUrl" : "http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1",
"resource" : {
"resourceType" : "DeviceRequest",
"id" : "PCT-DeviceRequest-1",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest"
]
},
"status" : "active",
"intent" : "proposal",
"codeCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "L1820",
"display" : "KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT"
}
]
},
"subject" : {
🔗 "reference" : "Patient/patient1001"
}
}
}
]
}
}
]
}
IG © 2025+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0 based on FHIR 4.0.1. Generated 2025-09-09
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