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-draft 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

• Narrative Content
• XML
• JSON
• TTL

: PCT-GFE-Summary-MRI - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "PCT-GFE-Summary-MRI",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PCT-GFE-Summary-MRI</b></p><a name=\"PCT-GFE-Summary-MRI\"> </a><a name=\"hcPCT-GFE-Summary-MRI\"> </a><a name=\"PCT-GFE-Summary-MRI-en-US\"> </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-gfe-summary.html\">PCT Good Faith Estimate  Summary</a></p></div><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=\"Bundle-PCT-AEOB-Packet-1.html#urn-uuid-9c05d948-b931-4bff-8766-18b99b0650d4\">Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-1234568; type = document; timestamp = 2025-01-10 11:01:00+0500</a></p><p><b>billablePeriod</b>: 2021-10-31 --&gt; (ongoing)</p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: ?rref?</p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">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><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.30}\">Unspecified focal traumatic brain injury</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">Principal Diagnosis</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup 400}\">Head trauma - concussion</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: extension = insurance,false; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --&gt; 2022-01-01</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>United States dollar</td></tr></table></div>"
  },
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
        "code" : "estimate-summary",
        "display" : "Estimate Summary"
      }
    ]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "urn:uuid:9c05d948-b931-4bff-8766-18b99b0650d4"
  },
  "billablePeriod" : {
    "start" : "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/ex-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"
  }
}