Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
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
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Bundle ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "PCT-GFE-Bundle-Inst-1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle> ] ) ] ; # fhir:identifier [ fhir:system [ fhir:v "http://example.com/identifiers/bundle"^^xsd:anyURI ] ; fhir:value [ fhir:v "59688475-2324-3242-23473847" ] ] ; # fhir:type [ fhir:v "collection"] ; # fhir:timestamp [ fhir:v "2021-11-09T11:01:00+05:00"^^xsd:dateTime] ; # fhir:entry ( [ fhir:id [ fhir:v "PCT-GFE-Summary-1" ] ; fhir:fullUrl [ fhir:v "http://example.org/fhir/Claim/PCT-GFE-Summary-1"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Claim/PCT-GFE-Summary-1> ) ] [ fhir:id [ fhir:v "PCT-GFE-Institutional-1" ] ; fhir:fullUrl [ fhir:v "http://example.org/fhir/Claim/PCT-GFE-Institutional-1"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Claim/PCT-GFE-Institutional-1> ) ] [ fhir:id [ fhir:v "Submitter-Org-1" ] ; fhir:fullUrl [ fhir:v "http://example.org/fhir/Organization/Submitter-Org-1"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Organization/Submitter-Org-1> ) ] [ fhir:id [ fhir:v "org1001" ] ; fhir:fullUrl [ fhir:v "http://example.org/fhir/Organization/org1001"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Organization/org1001> ) ] [ fhir:id [ fhir:v "patient1001" ] ; fhir:fullUrl [ fhir:v "http://example.org/fhir/Patient/patient1001"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Patient/patient1001> ) ] [ fhir:fullUrl [ fhir:v "http://example.org/fhir/Coverage/coverage1001"^^xsd:anyURI ] ; ( fhir:resource <http://example.org/fhir/Coverage/coverage1001> ) ] ) . # <http://example.org/fhir/Claim/PCT-GFE-Summary-1> a fhir:Claim ; fhir:id [ fhir:v "PCT-GFE-Summary-1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "additional" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><a name=\"PCT-GFE-Summary-1\"></a><a name=\"hcPCT-GFE-Summary-1\"></a></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\">Resource Claim "PCT-GFE-Summary-1"</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-summary.html\">PCT Good Faith Estimate Summary</a></p></div><p><b>status</b>: active</p><p><b>type</b>: Estimate Summary <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"CodeSystem-PCTEstimateTypeSummaryCSTemporaryTrialUse.html\">PCT Estimate Type Code System</a>#estimate-summary)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Patient/patient1001</a> " BETTERHALF"</p><p><b>billablePeriod</b>: 2021-10-31 --> 2021-10-31</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> "Umbrella Insurance Company"</p><p><b>provider</b>: <span>??</span></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html\">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage/coverage1001</a></td></tr></table><h3>Totals</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>USD</td></tr></table></div>" ] ; # fhir:status [ fhir:v "active"] ; # fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"^^xsd:anyURI ] ; fhir:code [ fhir:v "estimate-summary" ] ; fhir:display [ fhir:v "Estimate Summary" ] ] ) ] ; # fhir:use [ fhir:v "predetermination"] ; # fhir:patient [ fhir:reference [ fhir:v "Patient/patient1001" ] ] ; # fhir:billablePeriod [ fhir:start [ fhir:v "2021-10-31"^^xsd:date ] ; fhir:end [ fhir:v "2021-10-31"^^xsd:date ] ] ; # fhir:created [ fhir:v "2021-10-05"^^xsd:date] ; # fhir:insurer [ fhir:reference [ fhir:v "Organization/org1001" ] ] ; # fhir:provider [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/data-absent-reason"^^xsd:anyURI ] ; fhir:value [ fhir:v "not-applicable" ] ] ) ] ; # fhir:priority [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ; fhir:code [ fhir:v "normal" ] ] ) ] ; # fhir:diagnosis ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "S06.30" ] ; fhir:display [ fhir:v "Unspecified focal traumatic brain injury" ] ] ) ] ; ( fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"^^xsd:anyURI ] ; fhir:code [ fhir:v "principal" ] ] ) ] ) ; fhir:packageCode [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"^^xsd:anyURI ] ; fhir:code [ fhir:v "400" ] ; fhir:display [ fhir:v "Head trauma - concussion" ] ] ) ] ] ) ; # fhir:insurance ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:focal [ fhir:v "true"^^xsd:boolean ] ; fhir:coverage [ fhir:reference [ fhir:v "Coverage/coverage1001" ] ] ] ) ; # fhir:total [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] . # <http://example.org/fhir/Claim/PCT-GFE-Institutional-1> a fhir:Claim ; fhir:id [ fhir:v "PCT-GFE-Institutional-1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "additional" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><a name=\"PCT-GFE-Institutional-1\"></a><a name=\"hcPCT-GFE-Institutional-1\"></a></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\">Resource Claim "PCT-GFE-Institutional-1"</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-davinci-pct-gfe-institutional.html\">PCT Good Faith Estimate Institutional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1021</p><p><b>GFEDisclaimer</b>: For estimation purposes only</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><blockquote><p><b>url</b></p><code>linkingIdentifier</code></blockquote><p><b>value</b>: 223452-2342-2435-008001</p><blockquote><p><b>url</b></p><code>plannedPeriodOfService</code></blockquote><p><b>value</b>: 2021-10-31</p></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Patient/patient1001</a> " BETTERHALF"</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> "Umbrella Insurance Company"</p><p><b>provider</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization/Submitter-Org-1</a> "GFE Service Help INC."</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-payeetype.html\">Payee Type Codes</a>#provider)</span></td></tr></table><p><b>referral</b>: <span>: Referral Number</span></p><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Type of Bill <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"CodeSystem-PCTSupportingInfoType.html\">PCT GFE Supporting Info Type Code System</a>#typeofbill)</span></td><td>Hospital Inpatient (Part A) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCTypeOfBill.html\">AHA NUBC Type Of Bill Codes</a>#011X)</span></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Unspecified focal traumatic brain injury <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#S06.30)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</span></td><td>Head trauma - concussion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-ex-diagnosisrelatedgroup.html\">Example Diagnosis Related Group Codes</a>#400)</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage/coverage1001</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</p><p><b>sequence</b>: 1</p><p><b>revenue</b>: Magnetic Resonance Technology (MRT) - Brain/brain stem <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-AHANUBCRevenueCodes.html\">AHA NUBC Revenue Codes</a>#0611)</span></p><p><b>productOrService</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>modifier</b>: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-CPT.html\">Current Procedural Terminology (CPT®)</a>#70551)</span></p><p><b>serviced</b>: 2021-10-31</p><p><b>quantity</b>: 1</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>USD</td></tr></table></blockquote><h3>Totals</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>USD</td></tr></table></div>" ] ; # fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology"^^xsd:anyURI ] ; fhir:value [ fhir:v "EEMM1021" ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer"^^xsd:anyURI ] ; fhir:value [ fhir:v "For estimation purposes only" ] ] [ ( fhir:extension [ fhir:url [ fhir:v "linkingIdentifier"^^xsd:anyURI ] ; fhir:value [ fhir:v "223452-2342-2435-008001" ] ] [ fhir:url [ fhir:v "plannedPeriodOfService"^^xsd:anyURI ] ; fhir:value [ fhir:v "2021-10-31"^^xsd:date ] ] ) ; fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"^^xsd:anyURI ] ] ) ; # fhir:identifier ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ] ; fhir:code [ fhir:v "PLAC" ] ; fhir:display [ fhir:v "Placer Identifier" ] ] ) ] ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ] ; fhir:value [ fhir:v "GFEProviderAssignedID0001" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "institutional" ] ; fhir:display [ fhir:v "Institutional" ] ] ) ] ; # fhir:use [ fhir:v "predetermination"] ; # fhir:patient [ fhir:reference [ fhir:v "Patient/patient1001" ] ] ; # fhir:created [ fhir:v "2021-10-05"^^xsd:date] ; # fhir:insurer [ fhir:reference [ fhir:v "Organization/org1001" ] ] ; # fhir:provider [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy"^^xsd:anyURI ] ; fhir:value [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://nucc.org/provider-taxonomy"^^xsd:anyURI ] ; fhir:code [ fhir:v "2085D0003X" ] ; fhir:display [ fhir:v "Diagnostic Neuroimaging (Radiology) Physician" ] ] ) ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling"^^xsd:anyURI ] ; fhir:value [ fhir:v "true"^^xsd:boolean ] ] ) ; fhir:reference [ fhir:v "Organization/Submitter-Org-1" ] ] ; # fhir:priority [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ; fhir:code [ fhir:v "normal" ] ] ) ] ; # fhir:payee [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/payeetype"^^xsd:anyURI ] ; fhir:code [ fhir:v "provider" ] ] ) ] ] ; # fhir:referral [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber"^^xsd:anyURI ] ; fhir:value [ fhir:v "REF12022002-121" ] ] ) ; fhir:display [ fhir:v "Referral Number" ] ] ; # fhir:supportingInfo ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:category [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType"^^xsd:anyURI ] ; fhir:code [ fhir:v "typeofbill" ] ] ) ] ; fhir:code [ ( fhir:coding [ fhir:system [ fhir:v "https://www.nubc.org/CodeSystem/TypeOfBill"^^xsd:anyURI ] ; fhir:code [ fhir:v "011X" ] ; fhir:display [ fhir:v "Hospital Inpatient (Part A)" ] ] ) ] ] ) ; # fhir:diagnosis ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:diagnosis [ a fhir:CodeableConcept ; ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ; fhir:code [ fhir:v "S06.30" ] ; fhir:display [ fhir:v "Unspecified focal traumatic brain injury" ] ] ) ] ; ( fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"^^xsd:anyURI ] ; fhir:code [ fhir:v "principal" ] ] ) ] ) ; fhir:packageCode [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"^^xsd:anyURI ] ; fhir:code [ fhir:v "400" ] ; fhir:display [ fhir:v "Head trauma - concussion" ] ] ) ] ] ) ; # fhir:insurance ( [ fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:focal [ fhir:v "true"^^xsd:boolean ] ; fhir:coverage [ fhir:reference [ fhir:v "Coverage/coverage1001" ] ] ] ) ; # fhir:item ( [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription"^^xsd:anyURI ] ; fhir:value [ fhir:v "Imaging" ] ] ) ; fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ; fhir:revenue [ ( fhir:coding [ fhir:system [ fhir:v "https://www.nubc.org/CodeSystem/RevenueCodes"^^xsd:anyURI ] ; fhir:code [ fhir:v "0611" ] ; fhir:display [ fhir:v "Magnetic Resonance Technology (MRT) - Brain/brain stem" ] ] ) ] ; fhir:productOrService [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "70551" ] ; fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ) ] ; ( fhir:modifier [ ( fhir:coding [ fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ; fhir:code [ fhir:v "70551" ] ; fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ) ] ) ; fhir:serviced [ fhir:v "2021-10-31"^^xsd:date ] ; fhir:quantity [ fhir:value [ fhir:v "1"^^xsd:decimal ] ] ; fhir:net [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] ] ) ; # fhir:total [ fhir:value [ fhir:v "200"^^xsd:decimal ] ; fhir:currency [ fhir:v "USD" ] ] . # <http://example.org/fhir/Organization/Submitter-Org-1> a fhir:Organization ; fhir:id [ fhir:v "Submitter-Org-1"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "additional" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><a name=\"Submitter-Org-1\"></a><a name=\"hcSubmitter-Org-1\"></a></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\">Resource Organization "Submitter-Org-1"</p><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>: Non-Healthcare Business or Corporation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html\">Organization type</a>#bus)</span></p><p><b>name</b>: GFE Service Help INC.</p><h3>Contacts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Purpose</b></td><td><b>Name</b></td><td><b>Telecom</b></td></tr><tr><td style=\"display: none\">*</td><td>GFE-related <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"CodeSystem-PCTOrgContactPurposeType.html\">PCT Organization Contact Purpose Type Code System</a>#GFERELATED)</span></td><td>Clara Sender</td><td>ph: 781-632-3209(WORK), <a href=\"mailto:csender@GFEServiceHelp.com\">csender@GFEServiceHelp.com</a></td></tr></table></div>" ] ; # fhir:identifier ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "ETIN" ] ] ) ] ; fhir:value [ fhir:v "ETIN-10010301" ] ] ) ; # fhir:active [ fhir:v "true"^^xsd:boolean] ; # fhir:type ( [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/organization-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "bus" ] ] ) ] ) ; # fhir:name [ fhir:v "GFE Service Help INC."] ; # fhir:contact ( [ fhir:purpose [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType"^^xsd:anyURI ] ; fhir:code [ fhir:v "GFERELATED" ] ] ) ] ; fhir:name [ fhir:text [ fhir:v "Clara Sender" ] ] ; ( fhir:telecom [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "781-632-3209" ] ; fhir:use [ fhir:v "work" ] ] [ fhir:system [ fhir:v "email" ] ; fhir:value [ fhir:v "csender@GFEServiceHelp.com" ] ; fhir:use [ fhir:v "work" ] ] ) ] ) . # <http://example.org/fhir/Organization/org1001> a fhir:Organization ; fhir:id [ fhir:v "org1001"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "additional" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><a name=\"org1001\"></a><a name=\"hcorg1001\"></a></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\">Resource Organization "org1001"</p><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>: Payer <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-organization-type.html\">Organization type</a>#pay)</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>" ] ; # fhir:identifier ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"^^xsd:anyURI ] ; fhir:code [ fhir:v "ETIN" ] ] ) ] ; fhir:value [ fhir:v "ETIN-3200002" ] ] ) ; # fhir:active [ fhir:v "true"^^xsd:boolean] ; # fhir:type ( [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/organization-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "pay" ] ; fhir:display [ fhir:v "Payer" ] ] ) ] ) ; # fhir:name [ fhir:v "Umbrella Insurance Company"] ; # fhir:telecom ( [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "860-547-5001" ] ; fhir:use [ fhir:v "work" ] ] ) ; # fhir:address ( [ ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode"^^xsd:anyURI ] ; fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "urn:iso:std:iso:3166:-2"^^xsd:anyURI ] ; fhir:code [ fhir:v "US-CT" ] ] ] ) ; ( fhir:line [ fhir:v "680 Asylum Street" ] ) ; fhir:city [ fhir:v "Hartford" ] ; fhir:state [ fhir:v "CT" ] ; fhir:postalCode [ fhir:v "06155" ] ; fhir:country [ fhir:v "US" ] ] ) . # <http://example.org/fhir/Patient/patient1001> a fhir:Patient ; fhir:id [ fhir:v "patient1001"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "additional" ] ; fhir: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>" ] ; # fhir:identifier ( [ fhir:system [ fhir:v "http://example.com/identifiers/patient"^^xsd:anyURI ] ; fhir:value [ fhir:v "1001" ] ] ) ; # fhir:name ( [ fhir:text [ fhir:v "Eve Betterhalf" ] ; fhir:family [ fhir:v "Betterhalf" ] ; ( fhir:given [ fhir:v "Eve" ] ) ] ) ; # fhir:telecom ( [ fhir:system [ fhir:v "phone" ] ; fhir:value [ fhir:v "781-949-4949" ] ; fhir:use [ fhir:v "mobile" ] ] ) ; # fhir:gender [ fhir:v "female"] ; # fhir:birthDate [ fhir:v "1955-07-23"^^xsd:date] ; # fhir:address ( [ fhir:text [ fhir:v "222 Burlington Road, Bedford MA 01730" ] ] ) ; # fhir:maritalStatus [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"^^xsd:anyURI ] ; fhir:code [ fhir:v "U" ] ; fhir:display [ fhir:v "unmarried" ] ] ) ] ; # fhir:communication ( [ fhir:language [ ( fhir:coding [ fhir:system [ fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ] ; fhir:code [ fhir:v "en-US" ] ; fhir:display [ fhir:v "English (United States)" ] ] ) ] ; fhir:preferred [ fhir:v "true"^^xsd:boolean ] ] ) . # <http://example.org/fhir/Coverage/coverage1001> a fhir:Coverage ; fhir:id [ fhir:v "coverage1001"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "additional" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><a name=\"coverage1001\"></a><a name=\"hccoverage1001\"></a></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\">Resource Coverage "coverage1001"</p><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\">Patient/patient1001</a> " BETTERHALF"</p><p><b>relationship</b>: Self <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-subscriber-relationship.html\">SubscriberPolicyholder Relationship Codes</a>#self)</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href=\"Organization-org1001.html\">Organization/org1001</a> "Umbrella Insurance Company"</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>Plan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-coverage-class.html\">Coverage Class Codes</a>#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>Copay Percentage <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\">(<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-coverage-copay-type.html\">Coverage Copay Type Codes</a>#copaypct)</span></td><td>20</td></tr></table></div>" ] ; # fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"^^xsd:anyURI ] ; fhir:value [ fhir:v "insurance" ] ] [ fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared"^^xsd:anyURI ] ; fhir:value [ fhir:v "false"^^xsd:boolean ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:subscriberId [ fhir:v "PFP123450000"] ; # fhir:beneficiary [ fhir:reference [ fhir:v "Patient/patient1001" ] ] ; # fhir:relationship [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/subscriber-relationship"^^xsd:anyURI ] ; fhir:code [ fhir:v "self" ] ; fhir:display [ fhir:v "Self" ] ] ) ] ; # fhir:period [ fhir:start [ fhir:v "2021-01-01"^^xsd:date ] ; fhir:end [ fhir:v "2022-01-01"^^xsd:date ] ] ; # fhir:payor ( [ fhir:reference [ fhir:v "Organization/org1001" ] ] ) ; # fhir:class ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-class"^^xsd:anyURI ] ; fhir:code [ fhir:v "plan" ] ; fhir:display [ fhir:v "Plan" ] ] ) ] ; fhir:value [ fhir:v "Premim Family Plus" ] ; fhir:name [ fhir:v "Premim Family Plus Plan" ] ] ) ; # fhir:costToBeneficiary ( [ fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/coverage-copay-type"^^xsd:anyURI ] ; fhir:code [ fhir:v "copaypct" ] ; fhir:display [ fhir:v "Copay Percentage" ] ] ) ] ; fhir:value [ a fhir:Quantity ; fhir:value [ fhir:v "20"^^xsd:decimal ] ] ] ) . #
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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