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

Patient Cost Transparency Implementation Guide
2.0.0 - STU 2 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 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Example Bundle: PCT-GFE-Packet-Inst-1

Document Details

Profile: PCT GFE Packet

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

Document Subject

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

Marital Status:

unmarried

Contact Details:

ph: 781-949-4949(MOBILE)
222 Burlington Road, Bedford MA 01730

Language:

English (United States) (preferred)

Document Content

Coverage Section

Generated Narrative: Coverage selfpaycoverage2001

Profile: PCT Coverage

Extension Definition for Coverage.kind for Version 5.0: self-pay

Self-Pay Declared: true

status: Active

subscriberId: Absent because : not-applicable

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

relationship: Self

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

GFE Section

Generated Narrative: Claim PCT-GFE-Institutional-1

Profile: PCT Good Faith Estimate Institutional

ProviderEventMethodology: EEMM1021

GFEDisclaimer: For estimation purposes only

GFEServiceLinkingInfo
linkingIdentifier: http://example.org/Claim/identifiers/223452-2342-2435-008001
plannedPeriodOfService: 2021-10-31

identifier: Placer Identifier/GFEProviderAssignedID0001

status: Active

type: Institutional

use: Predetermination

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

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: Organization GFE Service Help INC.

priority: Normal

Payees

Type

Provider

referral: Referral Number

SupportingInfos

Sequence

Category

Code

1

Type of Bill

Hospital Inpatient (Part A)

Diagnoses

Sequence

Diagnosis[x]

Type

PackageCode

1

Unspecified focal traumatic brain injury

Principal Diagnosis

Head trauma - concussion

Insurances

Sequence

Focal

Coverage

1

true

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

item
Service Description: Imaging
sequence: 1
revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
serviced: 2021-10-31
quantity: 1
Nets
- Value Currency
* 200 United States dollar

Totals

Value

Currency

200

United States dollar

GFE Section

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

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

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

organization: Umbrella Insurance Company

Requested Services

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

Additional Resources Included in Document

Entry 2 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

Eve Betterhalf female, DoB: 1955-07-23 ( http://example.com/identifiers/patient/1001)
Marital Status: unmarried
Contact Details:
ph: 781-949-4949(MOBILE)
222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)

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

Resource Coverage:

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

Entry 4 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1

Resource Organization:

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

Entry 5 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

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

Entry 6 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1

Resource Bundle:

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

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

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

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

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

Entry 3 - fullUrl = http://example.org/fhir/Organization/Submitter-Org-1
Resource Organization:

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

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

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

Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf female, DoB: 1955-07-23 ( http://example.com/identifiers/patient/1001)
Marital Status: unmarried
Contact Details:
ph: 781-949-4949(MOBILE)
222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)

Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:

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

Entry 7 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1

Resource Bundle:

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

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

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

Entry 2 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf female, DoB: 1955-07-23 ( http://example.com/identifiers/patient/1001)
Marital Status: unmarried
Contact Details:
ph: 781-949-4949(MOBILE)
222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)

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

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

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

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

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

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

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IG © 2025+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0 based on FHIR 4.0.1. Generated 2025-09-17
Links: Table of Contents | QA Report | Version History | | Propose a change