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
<Bundle xmlns="http://hl7.org/fhir">
<id value="PCT-GFE-Collection-Bundle-2"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-collection-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-2347384711"/>
</identifier>
<type value="collection"/>
<timestamp value="2024-03-29T11:01:00+05:00"/>
<entry id="patient1001">
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry id="coverage1001">
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
<valueBoolean value="false"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
<entry id="Submitter-Practitioner-1">
<fullUrl
value="http://example.org/fhir/Practitioner/Submitter-Practitioner-1"/>
<resource>
<Practitioner>
<id value="Submitter-Practitioner-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_Submitter-Practitioner-1"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner Submitter-Practitioner-1</b></p><a name="Submitter-Practitioner-1"> </a><a name="hcSubmitter-Practitioner-1"> </a><a name="Submitter-Practitioner-1-en-US"> </a><p><b>identifier</b>: National provider identifier/6456789016, Electronic Transmitter Identification Number/ETIN-20020001</p><p><b>active</b>: true</p><p><b>name</b>: Nora Ologist</p><p><b>telecom</b>: ph: 860-547-3301(Work), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></p></div>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="6456789016"/>
</identifier>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<system value="http://example.com/us-etin"/>
<value value="ETIN-20020001"/>
</identifier>
<active value="true"/>
<name>
<text value="Nora Ologist"/>
<family value="Ologist"/>
<given value="Nora"/>
</name>
<telecom>
<system value="phone"/>
<value value="860-547-3301"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="csender@GFEServiceHelp.com"/>
<use value="work"/>
</telecom>
</Practitioner>
</resource>
</entry>
<entry id="org1001">
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-CT"/>
</valueCoding>
</extension>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="PCT-GFE-Bundle-Prof-1">
<fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Bundle-Prof-1"/>
<resource>
<Bundle>
<id value="PCT-GFE-Bundle-Prof-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-23473847"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-09T11:01:00+05:00"/>
<entry id="PCT-GFE-Summary-MRI">
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Summary-MRI"/>
<resource>
<Claim>
<id value="PCT-GFE-Summary-MRI"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"/>
</meta>
<status value="active"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
<code value="estimate-summary"/>
<display value="Estimate Summary"/>
</coding>
</type>
<use value="predetermination"/>
<patient>🔗
<reference value="Patient/patient1001"/>
</patient>
<billablePeriod>
<start value="2021-10-31"/>
</billablePeriod>
<created value="2021-10-05"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
<valueCode value="not-applicable"/>
</extension>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display
value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry id="PCT-GFE-Professional-MRI">
<fullUrl
value="http://example.org/fhir/Claim/PCT-GFE-Professional-MRI"/>
<resource>
<Claim>
<id value="PCT-GFE-Professional-MRI"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"/>
</meta>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
<valueString value="EEMM1022"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
<extension url="linkingIdentifier">
<valueString value="223452-2342-2435-008001"/>
</extension>
<extension url="plannedPeriodOfService">
<valueDate value="2021-10-31"/>
</extension>
</extension>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PLAC"/>
<display value="Placer Identifier"/>
</coding>
</type>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<value value="GFEProviderAssignedID0002"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
<display value="Professional"/>
</coding>
</type>
<use value="predetermination"/>
<patient>🔗
<reference value="Patient/patient1001"/>
</patient>
<created value="2021-10-05"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>🔗
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
<valueCodeableConcept>
<coding>
<system value="http://nucc.org/provider-taxonomy"/>
<code value="2085D0003X"/>
<display
value="Diagnostic Neuroimaging (Radiology) Physician"/>
</coding>
</valueCodeableConcept>
</extension>
<reference value="Practitioner/Submitter-Practitioner-1"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
</payee>
<referral>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
<valueString value="REF12022002-122"/>
</extension>
<display value="Referral Number"/>
</referral>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display
value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
<valueString value="Imaging"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum">
<valueIdentifier>
<value value="GFEBillingProviderLineItemCtrlNum-0001"/>
</valueIdentifier>
</extension>
<sequence value="1"/>
<productOrService>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="70551"/>
<display
value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
</coding>
</productOrService>
<modifier>
<coding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="70551"/>
<display
value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
</coding>
</modifier>
<servicedDate value="2021-10-31"/>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
<display value="Inpatient Hospital"/>
</coding>
</locationCodeableConcept>
<quantity>
<value value="1"/>
</quantity>
<unitPrice>
<value value="200"/>
<currency value="USD"/>
</unitPrice>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
</item>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry id="Submitter-Practitioner-1">
<fullUrl
value="http://example.org/fhir/Practitioner/Submitter-Practitioner-1"/>
<resource>
<Practitioner>
<id value="Submitter-Practitioner-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"/>
</meta>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="6456789016"/>
</identifier>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<system value="http://example.com/us-etin"/>
<value value="ETIN-20020001"/>
</identifier>
<active value="true"/>
<name>
<text value="Nora Ologist"/>
<family value="Ologist"/>
<given value="Nora"/>
</name>
<telecom>
<system value="phone"/>
<value value="860-547-3301"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="csender@GFEServiceHelp.com"/>
<use value="work"/>
</telecom>
</Practitioner>
</resource>
</entry>
<entry id="org1001">
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-CT"/>
</valueCoding>
</extension>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="patient1001">
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
<valueBoolean value="false"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
</Bundle>
</resource>
</entry>
<entry id="PCT-GFE-Missing-Bundle-1">
<fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1"/>
<resource>
<Bundle>
<id value="PCT-GFE-Missing-Bundle-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle"/>
</meta>
<type value="collection"/>
<timestamp value="2024-03-27T11:01:00+05:00"/>
<entry id="org1002">
<fullUrl value="http://example.org/fhir/Organization/org1002"/>
<resource>
<Organization>
<id value="org1002"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="org1002"></a><a name="hcorg1002"></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 "org1002"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: National provider identifier/1234568095, Tax ID number/TAX-3211001</p><p><b>active</b>: true</p><p><b>type</b>: Healthcare Provider <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>#prov)</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>
</text>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1234568095"/>
</identifier>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="TAX"/>
</coding>
</type>
<system value="urn:oid:2.16.840.1.113883.4.4"/>
<value value="TAX-3211001"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Boston Radiology Center"/>
<telecom>
<system value="phone"/>
<value value="781-232-3200"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-MA"/>
</valueCoding>
</extension>
<line value="32 Fruit Street"/>
<city value="Boston"/>
<state value="MA"/>
<postalCode value="02114"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="patient1001">
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry id="coverage1001">
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared">
<valueBoolean value="false"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
<entry id="org1001">
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="additional"/>
<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>
</text>
<identifier>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgIdentifierTypeCS"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/countrySubdivisionCode">
<valueCoding>
<system value="urn:iso:std:iso:3166:-2"/>
<code value="US-CT"/>
</valueCoding>
</extension>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="PCT-DeviceRequest-1">
<fullUrl
value="http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1"/>
<resource>
<DeviceRequest>
<id value="PCT-DeviceRequest-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><a name="PCT-DeviceRequest-1"></a><a name="hcPCT-DeviceRequest-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 DeviceRequest "PCT-DeviceRequest-1"</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-davinci-pct-devicerequest.html">PCT GFE DeviceRequest</a></p></div><p><b>status</b>: active</p><p><b>intent</b>: proposal</p><p><b>code</b>: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki">(HCPCSReleaseCodeSets#L1820)</span></p><p><b>subject</b>: <a href="Patient-patient1001.html">Patient/patient1001</a> " BETTERHALF"</p></div>
</text>
<status value="active"/>
<intent value="proposal"/>
<codeCodeableConcept>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="L1820"/>
<display
value="KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT"/>
</coding>
</codeCodeableConcept>
<subject>🔗
<reference value="Patient/patient1001"/>
</subject>
</DeviceRequest>
</resource>
</entry>
</Bundle>
</resource>
</entry>
</Bundle>
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-11-20
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