Patient Cost Transparency Implementation Guide
1.0.0 - STU 1
Patient Cost Transparency Implementation Guide
1.0.0 - STU 1
Patient Cost Transparency Implementation Guide, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional | Version: 1.0.0 | |||
| Active as of 2023-03-29 | Computable Name: PCTGFEInstitutional | |||
PCT Good Faith Estimate Institutional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for an institutional GFE submission.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Claim
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
  Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
 gfeSubmitter | 1..1 | Reference() | The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter | |
| gfeServiceLinkingInfo | S | 0..1 | (Complex) | GFE Service Linking Information. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo |
| providerEventMethodology | S | 0..1 | string | Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology |
| gfeDisclaimer | S | 0..* | string | Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer |
  Slices for identifier | 1..* | Identifier | Business Identifier for claim Slice: Unordered, Open by pattern:type | |
  identifier:PLAC | 1..1 | Identifier | Provider Assigned Identifier for GFE Claim | |
   type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Placer Identifier | |
 system | S | 0..1 | uri | The namespace for the identifier value |
 value | 1..1 | string | The value that is unique | |
 identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
 type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
| type | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| use | 1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
 patient | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | |
| billablePeriod | S | 0..1 | Period | Relevant time frame for the claim. This is per claim, whereas a planned period of service can span multiple claims. |
| insurer | 1..1 | Reference(PCT Organization) | Target | |
| provider | 1..1 | Reference(PCT Organization) | Billing provider - party responsible for the GFE | |
| extension | 1..* | Extension | Extension | |
| providerTaxonomy | 1..1 | CodeableConcept | Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: US Core Provider Role (NUCC) (extensible) | |
| consentForBalanceBilling | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling |
| priority | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (required) | |
| payee | S | 0..1 | BackboneElement | Recipient of benefits payable |
| party | 0..1 | Reference(PCT Practitioner | PCT Organization) | Recipient reference | |
| referral | ||||
| extension | 1..* | Extension | Extension | |
| referralNumber | 1..1 | string | Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber | |
| Slices for careTeam | S | 0..* | BackboneElement | Members of the care team Slice: Unordered, Open by pattern:role |
| careTeam:All Slices | Content/Rules for all slices | |||
 provider | 1..1 | Reference(PCT Practitioner | PCT Organization) | Practitioner or organization | |
| role | 1..1 | CodeableConcept | Function within the team Binding: PCT Care Team Role Value Set (required) | |
 qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: US Core Provider Role (NUCC) (required) | |
| careTeam:attending | S | 0..1 | BackboneElement | Members of the care team |
| provider | 1..1 | Reference(PCT Practitioner) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: attending | |
| qualification | 1..1 | CodeableConcept | Practitioner credential or specialization | |
| careTeam:operating | S | 0..2 | BackboneElement | Members of the care team |
| provider | 1..1 | Reference(PCT Practitioner) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: operating | |
| careTeam:rendering | S | 0..1 | BackboneElement | Members of the care team |
| provider | 1..1 | Reference(PCT Practitioner) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rendering | |
| careTeam:referring | S | 0..1 | BackboneElement | Members of the care team |
| role | 0..1 | CodeableConcept | Function within the team Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referring | |
| Slices for supportingInfo | S | 1..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: PCT Supporting Info Type Value Set (extensible) | |
| supportingInfo:typeOfBill | 1..1 | BackboneElement | Supporting information | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
| code | 1..1 | CodeableConcept | Type of information Binding: PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set (required) | |
| supportingInfo:serviceFacility | S | 0..1 | BackboneElement | Service Facility |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
| value[x] | 1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Open by type:$this | |
| valueReference | 1..1 | Reference(PCT Organization) | Data to be provided | |
| supportingInfo:drg | 0..1 | BackboneElement | Supporting information | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
| code | 0..1 | CodeableConcept | Type of information Binding: US Claim DRG Codes (required) | |
| supportingInfo:pointoforigin | 0..1 | BackboneElement | Supporting information | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pointoforigin | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Point Of Origin (required) | |
| supportingInfo:admtype | 0..1 | BackboneElement | Supporting information | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority (Type) of Admission or Visit (required) | |
| Slices for diagnosis | S | 1..* | BackboneElement | Pertinent diagnosis information Slice: Unordered, Open by pattern:type |
| diagnosis:All Slices | Content/Rules for all slices | |||
| type | S | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: PCT Diagnosis Type Value Set (required) |
| diagnosis:principal | 1..1 | BackboneElement | Pertinent diagnosis information | |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier Required Pattern: 1 | |
 diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: principal | |
| diagnosis:admitting | S | 0..1 | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admitting | |
| diagnosis:patientReasonForVisit | S | 0..3 | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientReasonForVisit | |
| diagnosis:externalcauseofinjury | S | 0..12 | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: externalCauseOfInjury | |
| diagnosis:other | S | 0..24 | BackboneElement | Pertinent diagnosis information |
| diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: other | |
| Slices for procedure | S | 0..* | BackboneElement | Clinical procedures performed Slice: Unordered, Open by pattern:type |
| procedure:All Slices | Content/Rules for all slices | |||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| type | S | 0..* | CodeableConcept | Category of Procedure Binding: PCT Procedure Type Value Set (required) |
| procedure:principal | S | 0..1 | BackboneElement | Principal clinical procedure performed |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| sequence | 1..1 | positiveInt | Procedure instance identifier Required Pattern: 1 | |
| type | 1..1 | CodeableConcept | Category of Procedure Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: principal | |
| procedure[x] | 1..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10 Procedure Codes (required) | |
| procedure:other | S | 0..24 | BackboneElement | Clinical procedures performed |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| type | 1..1 | CodeableConcept | Category of Procedure Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: other | |
| procedure[x] | 1..1 | CodeableConcept | Specific clinical procedure Binding: PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required) | |
| insurance | ||||
| coverage | 1..1 | Reference(PCT Coverage) | Insurance information | |
| preAuthRef | 0..1 | string | Prior authorization reference number | |
| accident | ||||
| location[x] | 0..1 | Address | Where the event occurred | |
| country | 0..1 | string | Country (e.g. can be ISO 3166 2 or 3 letter code) Binding: Iso3166-1-2 (required) | |
| item | 1..999 | BackboneElement | Product or service provided | |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| gfeBillingProviderLineItemCtrlNum | S | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| ProviderEventMethodology | S | 0..1 | string | Provider Event Methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology |
| revenue | 1..1 | CodeableConcept | Revenue or cost center code - must provide a value for the Institutional case Binding: PCT GFE NUBC Revenue Value Set (required) | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |
| modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) |
| serviced[x] | S | 1..1 | date, Period | This is the planned or estimated date(s)s of service |
| locationCodeableConcept | S | 0..1 | CodeableConcept | Place of service or where product was supplied Binding: PCT GFE CMS Place of Service Value Set (required) |
| quantity | 1..1 | SimpleQuantity | Count of products or services | |
| net | 1..1 | Money | Total charge amount for the service line | |
| detail | S | 0..* | BackboneElement | Drug Identification Information |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: PCT GFE Item NDC Value Set (required) | |
| quantity | S | 0..1 | SimpleQuantity | Count of products or services |
| total | 1..1 | Money | Total GFE Charges Submitted | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Claim.priority | required | ProcessPriorityCodes |
| Claim.careTeam.role | required | PCTCareTeamRoleVS |
| Claim.careTeam.qualification | required | USCoreProviderRoleNucc |
| Claim.supportingInfo.category | extensible | PCTSupportingInfoTypeVS (a valid code from PCT GFE Supporting Info Type Code System) |
| Claim.supportingInfo:typeOfBill.code | required | PCTGFETypeOfBillVS |
| Claim.supportingInfo:drg.code | required | USClaimDRGCodes |
| Claim.supportingInfo:pointoforigin.code | required | AHANUBCPointOfOriginVS |
| Claim.supportingInfo:admtype.code | required | AHANUBCPriorityTypeOfAdmissionOrVisitVS (a valid code from http://terminology.hl7.org/CodeSystem/AHANUBCPriorityTypeOfAdmitOrVisit) |
| Claim.diagnosis.type | required | PCTDiagnosisTypeVS |
| Claim.diagnosis:principal.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:admitting.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:patientReasonForVisit.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:externalcauseofinjury.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:other.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.procedure.type | required | PCTProcedureTypeVS |
| Claim.procedure:principal.procedure[x] | required | ICD10ProcedureCodes |
| Claim.procedure:other.procedure[x] | required | PCTProcedureSurgicalCodes |
| Claim.accident.location[x].country | required | Iso3166-1-2 |
| Claim.item.revenue | required | PCTGFEItemRevenueVS |
| Claim.item.productOrService | required | USClaimMedicalProductOrServiceCodes |
| Claim.item.modifier | required | PCTGFEItemCptHcpcsVS |
| Claim.item.locationCodeableConcept | required | PCTGFECMSPOS |
| Claim.item.detail.productOrService | required | PCTGFEItemNDCVS |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| gfeSubmitter | 1..1 | Reference() | The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter | |
| gfeServiceLinkingInfo | S | 0..1 | (Complex) | GFE Service Linking Information. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo |
| providerEventMethodology | S | 0..1 | string | Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology |
| gfeDisclaimer | S | 0..* | string | Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | 1..* | Identifier | Business Identifier for claim Slice: Unordered, Open by pattern:type | |
| identifier:PLAC | 1..1 | Identifier | Provider Assigned Identifier for GFE Claim | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Placer Identifier | |
| system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | Σ | 1..1 | string | The value that is unique Example General: 123456 |
| identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: predetermination |
| patient | Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services |
| billablePeriod | SΣ | 0..1 | Period | Relevant time frame for the claim. This is per claim, whereas a planned period of service can span multiple claims. |
| created | Σ | 1..1 | dateTime | Resource creation date |
| insurer | Σ | 1..1 | Reference(PCT Organization) | Target |
| provider | Σ | 1..1 | Reference(PCT Organization) | Billing provider - party responsible for the GFE |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| providerTaxonomy | 1..1 | CodeableConcept | Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: US Core Provider Role (NUCC) (extensible) | |
| consentForBalanceBilling | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling |
| priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (required) |
| payee | S | 0..1 | BackboneElement | Recipient of benefits payable |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |
| party | 0..1 | Reference(PCT Practitioner | PCT Organization) | Recipient reference | |
| Slices for careTeam | S | 0..* | BackboneElement | Members of the care team Slice: Unordered, Open by pattern:role |
| careTeam:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(PCT Practitioner | PCT Organization) | Practitioner or organization | |
| role | 1..1 | CodeableConcept | Function within the team Binding: PCT Care Team Role Value Set (required) | |
| qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: US Core Provider Role (NUCC) (required) | |
| careTeam:attending | S | 0..1 | BackboneElement | Members of the care team |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(PCT Practitioner) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: attending | |
| qualification | 1..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |
| careTeam:operating | S | 0..2 | BackboneElement | Members of the care team |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(PCT Practitioner) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: operating | |
| careTeam:rendering | S | 0..1 | BackboneElement | Members of the care team |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(PCT Practitioner) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rendering | |
| careTeam:referring | S | 0..1 | BackboneElement | Members of the care team |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |
| role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referring | |
| Slices for supportingInfo | S | 1..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: PCT Supporting Info Type Value Set (extensible) | |
| supportingInfo:typeOfBill | 1..1 | BackboneElement | Supporting information | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
| code | 1..1 | CodeableConcept | Type of information Binding: PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set (required) | |
| supportingInfo:serviceFacility | S | 0..1 | BackboneElement | Service Facility |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
| Slices for value[x] | 1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Closed by type:$this | |
| value[x]:valueReference | 1..1 | Reference(PCT Organization) | Data to be provided | |
| supportingInfo:drg | 0..1 | BackboneElement | Supporting information | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
| code | 0..1 | CodeableConcept | Type of information Binding: US Claim DRG Codes (required) | |
| supportingInfo:pointoforigin | 0..1 | BackboneElement | Supporting information | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pointoforigin | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Point Of Origin (required) | |
| supportingInfo:admtype | 0..1 | BackboneElement | Supporting information | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority (Type) of Admission or Visit (required) | |
| Slices for diagnosis | S | 1..* | BackboneElement | Pertinent diagnosis information Slice: Unordered, Open by pattern:type |
| diagnosis:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
 diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept | CodeableConcept | |||
| diagnosisReference | Reference(Condition) | |||
| type | S | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: PCT Diagnosis Type Value Set (required) |
| diagnosis:principal | 1..1 | BackboneElement | Pertinent diagnosis information | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier Required Pattern: 1 | |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: principal | |
| diagnosis:admitting | S | 0..1 | BackboneElement | Pertinent diagnosis information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admitting | |
| diagnosis:patientReasonForVisit | S | 0..3 | BackboneElement | Pertinent diagnosis information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientReasonForVisit | |
| diagnosis:externalcauseofinjury | S | 0..12 | BackboneElement | Pertinent diagnosis information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
| diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) | |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: externalCauseOfInjury | |
| diagnosis:other | S | 0..24 | BackboneElement | Pertinent diagnosis information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
| diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required) |
| type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: other | |
| Slices for procedure | S | 0..* | BackboneElement | Clinical procedures performed Slice: Unordered, Open by pattern:type |
| procedure:All Slices | Content/Rules for all slices | |||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Procedure instance identifier | |
| type | S | 0..* | CodeableConcept | Category of Procedure Binding: PCT Procedure Type Value Set (required) |
| procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
| procedureCodeableConcept | CodeableConcept | |||
| procedureReference | Reference(Procedure) | |||
| procedure:principal | S | 0..1 | BackboneElement | Principal clinical procedure performed |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Procedure instance identifier Required Pattern: 1 | |
| type | 1..1 | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: principal | |
| procedure[x] | 1..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10 Procedure Codes (required) | |
| procedure:other | S | 0..24 | BackboneElement | Clinical procedures performed |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Procedure instance identifier | |
| type | 1..1 | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: other | |
| procedure[x] | 1..1 | CodeableConcept | Specific clinical procedure Binding: PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required) | |
| insurance | Σ | 1..* | BackboneElement | Patient insurance information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information |
| preAuthRef | 0..1 | string | Prior authorization reference number | |
| item | 1..999 | BackboneElement | Product or service provided | |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| gfeBillingProviderLineItemCtrlNum | S | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum |
| serviceDescription | 1..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | |
| ProviderEventMethodology | S | 0..1 | string | Provider Event Methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Item instance identifier | |
| revenue | 1..1 | CodeableConcept | Revenue or cost center code - must provide a value for the Institutional case Binding: PCT GFE NUBC Revenue Value Set (required) | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |
| modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) |
| serviced[x] | S | 1..1 | This is the planned or estimated date(s)s of service | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| Slices for location[x] | 0..1 | Place of service or where product was supplied Slice: Unordered, Open by type:$this Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| location[x]:locationCodeableConcept | S | 0..1 | CodeableConcept | Place of service or where product was supplied Binding: PCT GFE CMS Place of Service Value Set (required) |
| quantity | 1..1 | SimpleQuantity | Count of products or services | |
| net | 1..1 | Money | Total charge amount for the service line | |
| detail | S | 0..* | BackboneElement | Drug Identification Information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Item instance identifier | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: PCT GFE Item NDC Value Set (required) | |
| quantity | S | 0..1 | SimpleQuantity | Count of products or services |
| total | 1..1 | Money | Total GFE Charges Submitted | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Claim.identifier:PLAC.use | required | IdentifierUse |
| Claim.identifier:PLAC.type | extensible | Pattern: PLAC("Placer Identifier") |
| Claim.identifier:INTER.use | required | IdentifierUse |
| Claim.identifier:INTER.type | extensible | Pattern: INTER("Intermediary System Identifier") |
| Claim.status | required | FinancialResourceStatusCodes |
| Claim.type | extensible | Pattern: institutional |
| Claim.use | required | Pattern: predetermination |
| Claim.priority | required | ProcessPriorityCodes |
| Claim.payee.type | example | Claim Payee Type Codes |
| Claim.careTeam.role | required | PCTCareTeamRoleVS |
| Claim.careTeam.qualification | required | USCoreProviderRoleNucc |
| Claim.careTeam:attending.role | example | Pattern: attending |
| Claim.careTeam:attending.qualification | example | ExampleProviderQualificationCodes |
| Claim.careTeam:operating.role | example | Pattern: operating |
| Claim.careTeam:rendering.role | example | Pattern: rendering |
| Claim.careTeam:referring.role | example | Pattern: referring |
| Claim.supportingInfo.category | extensible | PCTSupportingInfoTypeVS (a valid code from PCT GFE Supporting Info Type Code System) |
| Claim.supportingInfo:typeOfBill.category | example | Pattern: typeofbill |
| Claim.supportingInfo:typeOfBill.code | required | PCTGFETypeOfBillVS |
| Claim.supportingInfo:serviceFacility.category | example | Pattern: servicefacility |
| Claim.supportingInfo:drg.category | example | Pattern: drg |
| Claim.supportingInfo:drg.code | required | USClaimDRGCodes |
| Claim.supportingInfo:pointoforigin.category | example | Pattern: pointoforigin |
| Claim.supportingInfo:pointoforigin.code | required | AHANUBCPointOfOriginVS |
| Claim.supportingInfo:admtype.category | example | Pattern: admtype |
| Claim.supportingInfo:admtype.code | required | AHANUBCPriorityTypeOfAdmissionOrVisitVS (a valid code from http://terminology.hl7.org/CodeSystem/AHANUBCPriorityTypeOfAdmitOrVisit) |
| Claim.diagnosis.diagnosis[x] | example | ICD-10Codes |
| Claim.diagnosis.type | required | PCTDiagnosisTypeVS |
| Claim.diagnosis:principal.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:principal.type | example | Pattern: principal |
| Claim.diagnosis:admitting.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:admitting.type | example | Pattern: admitting |
| Claim.diagnosis:patientReasonForVisit.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:patientReasonForVisit.type | example | Pattern: patientReasonForVisit |
| Claim.diagnosis:externalcauseofinjury.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:externalcauseofinjury.type | example | Pattern: externalCauseOfInjury |
| Claim.diagnosis:other.diagnosis[x] | required | PCTDiagnosticCodes |
| Claim.diagnosis:other.type | example | Pattern: other |
| Claim.procedure.type | required | PCTProcedureTypeVS |
| Claim.procedure.procedure[x] | example | ICD-10ProcedureCodes |
| Claim.procedure:principal.type | example | Pattern: principal |
| Claim.procedure:principal.procedure[x] | required | ICD10ProcedureCodes |
| Claim.procedure:other.type | example | Pattern: other |
| Claim.procedure:other.procedure[x] | required | PCTProcedureSurgicalCodes |
| Claim.item.revenue | required | PCTGFEItemRevenueVS |
| Claim.item.productOrService | required | USClaimMedicalProductOrServiceCodes |
| Claim.item.modifier | required | PCTGFEItemCptHcpcsVS |
| Claim.item.location[x] | example | ExampleServicePlaceCodes |
| Claim.item.location[x]:locationCodeableConcept | required | PCTGFECMSPOS |
| Claim.item.detail.productOrService | required | PCTGFEItemNDCVS |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| gfeSubmitter | 1..1 | Reference() | The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter | |||||
| gfeServiceLinkingInfo | S | 0..1 | (Complex) | GFE Service Linking Information. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo | ||||
| providerEventMethodology | S | 0..1 | string | Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology | ||||
| gfeDisclaimer | S | 0..* | string | Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| Slices for identifier | 1..* | Identifier | Business Identifier for claim Slice: Unordered, Open by pattern:type | |||||
| identifier:PLAC | 1..1 | Identifier | Provider Assigned Identifier for GFE Claim | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PLAC | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Placer Identifier | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: predetermination | ||||
| patient | Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | ||||
| billablePeriod | SΣ | 0..1 | Period | Relevant time frame for the claim. This is per claim, whereas a planned period of service can span multiple claims. | ||||
| created | Σ | 1..1 | dateTime | Resource creation date | ||||
| enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
| insurer | Σ | 1..1 | Reference(PCT Organization) | Target | ||||
| provider | Σ | 1..1 | Reference(PCT Organization) | Billing provider - party responsible for the GFE | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| providerTaxonomy | 1..1 | CodeableConcept | Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: US Core Provider Role (NUCC) (extensible) | |||||
| consentForBalanceBilling | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling | ||||
| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (required) | ||||
| fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related | 0..* | BackboneElement | Prior or corollary claims | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
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