Patient Cost Transparency Implementation Guide
1.1.0 - STU 1 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 1.1.0 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-GFE-Bundle-Inst-1

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


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

Resource Claim:

Generated Narrative: Claim

Resource Claim "PCT-GFE-Institutional-1"

Profile: PCT Good Faith Estimate Institutional

GFESubmitter: See above (Organization/Submitter-Org-1)

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: See above (Patient/patient1001)

created: 2021-10-05

insurer: See above (Organization/org1001)

provider: See above (Organization/Submitter-Org-1)

priority: Normal (Process Priority Codes#normal)

Payees

-Type
*Provider (Payee Type Codes#provider)

referral: : Referral Number

SupportingInfos

-SequenceCategoryCode
*1Type of Bill (PCT GFE Supporting Info Type Code System#typeofbill)Hospital Inpatient (Part A) (AHA NUBC Type Of Bill Codes#011X)

Diagnoses

-SequenceDiagnosis[x]Type
*1Unspecified focal traumatic brain injury (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#S06.30)Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-SequenceFocalCoverage
*1trueSee above (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

-ValueCurrency
*200USD

Totals

-ValueCurrency
*200USD


Entry 2 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1

Resource Organization:

Generated Narrative: 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

-PurposeNameTelecom
*GFE-related (PCT Organization Contact Purpose Type Code System#GFERELATED)Clara Senderph: 781-632-3209(WORK), csender@GFEServiceHelp.com


Entry 3 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

Generated Narrative: 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

Contacts

-TelecomAddress
*ph: 860-547-5001(WORK)680 Asylum Street Hartford CT 06155 US


Entry 4 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

Eve Betterhalf Female, DoB: 1955-07-23 ( id: 1001)


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

Resource Coverage:

Generated Narrative: Coverage

Resource Coverage "coverage1001"

Profile: PCT Coverage

status: ACTIVE

subscriberId: id: PFP123450000

beneficiary: See above (Patient/patient1001)

relationship: Self (SubscriberPolicyholder Relationship Codes#self)

period: 2021-01-01 --> 2022-01-01

Classes

-TypeValueName
*Plan (Coverage Class Codes#plan)id: Premim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage (Coverage Copay Type Codes#copaypct)20