Patient Cost Transparency Implementation Guide
2.0.1 - STU 2

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 2.0.1 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

## : PCT-AEOB-1 - TTL Representation

Page standards status: Informative

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:ExplanationOfBenefit ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "PCT-AEOB-1"] ; #
      fhir:meta [
        ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-1</b></p><a name=\"PCT-AEOB-1\"> </a><a name=\"hcPCT-AEOB-1\"> </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-aeob.html\">PCT Advanced EOB</a></p></div><p><b>GFE Reference</b>: <a href=\"Bundle-PCT-GFE-Bundle-Inst-1.html\">Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-23473847; type = collection; timestamp = 2021-11-09 11:01:00+0500</a></p><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href=\"http://example.org/out-of-network.html\">http://example.org/out-of-network.html</a></p><p><b>identifier</b>: Unique Claim Identifier/?ngen-9?</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Organization Boston Radiology Center</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>claim</b>: Identifier: <code>http://example.com/identifiers/bundle</code>/59688475-2324-3242-23473847</p><p><b>outcome</b>: Processing Complete</p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --&gt; 2022-01-01</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0611}\">Magnetic Resonance Technology (MRT) - Brain/brain stem</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 70551}\">Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material</span></p><p><b>modifier</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 70551}\">Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material</span></p><p><b>serviced</b>: 2022-01-01</p><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>200</td><td>United States dollar</td></tr></table><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS medicalmanagement}\">Medical Management</span></td></tr></table></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS medicalmanagement}\">Medical Management</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member Liability</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</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></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member liability</span></p><h3>Amounts</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>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible Amount</span></p><h3>Amounts</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>190</td><td>United States dollar</td></tr></table></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --&gt; 2023-01-01</p><blockquote><p><b>benefitBalance</b></p><p><b>category</b>: <span title=\"Codes:{https://x12.org/codes/service-type-codes 1}\">Medical Care</span></p><p><b>unit</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-unit individual}\">Individual</span></p><p><b>term</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-term annual}\">Annual</span></p><h3>Financials</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType allowed}\">Allowed</span></td><td><span title=\"US Dollar\">$1.00</span> (USD)</td><td><span title=\"US Dollar\">$1.00</span> (USD)</td></tr></table></blockquote></div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference>     ] ;
    fhir:value [
    a fhir:Reference ;
    fhir:l fhir:Bundle/PCT-GFE-Bundle-Inst-1 ;
    fhir:reference [ fhir:v "Bundle/PCT-GFE-Bundle-Inst-1" ]     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription>     ] ;
    fhir:value [
    a fhir:String ;
    fhir:v "Example service"     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink>     ] ;
    fhir:value [
    a fhir:Url ;
    fhir:v "http://example.org/out-of-network.html"^^xsd:anyURI ;
    fhir:l <http://example.org/out-of-network.html>     ]
      ] ) ; #
      fhir:identifier ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/v2-0203>         ] ;
    fhir:code [ fhir:v "UCID" ]       ] )     ]
      ] ) ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:type [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/claim-type>       ] ;
    fhir:code [ fhir:v "institutional" ] ;
    fhir:display [ fhir:v "Institutional" ]     ] )
      ] ; #
      fhir:use [ fhir:v "predetermination"] ; #
      fhir:patient [
    fhir:l fhir:Patient/patient1001 ;
    fhir:reference [ fhir:v "Patient/patient1001" ]
      ] ; #
      fhir:created [ fhir:v "2021-10-12"^^xsd:date] ; #
      fhir:insurer [
    fhir:l fhir:Organization/org1001 ;
    fhir:reference [ fhir:v "Organization/org1001" ]
      ] ; #
      fhir:provider [
    fhir:l fhir:Organization/org1002 ;
    fhir:reference [ fhir:v "Organization/org1002" ]
      ] ; #
      fhir:priority [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/processpriority>       ] ;
    fhir:code [ fhir:v "normal" ]     ] )
      ] ; #
      fhir:claim [
    fhir:identifier [
    fhir:system [
    fhir:v "http://example.com/identifiers/bundle"^^xsd:anyURI ;
    fhir:l <http://example.com/identifiers/bundle>       ] ;
    fhir:value [ fhir:v "59688475-2324-3242-23473847" ]     ]
      ] ; #
      fhir:outcome [ fhir:v "complete"] ; #
      fhir:insurance ( [
    fhir:focal [ fhir:v true ] ;
    fhir:coverage [
    fhir:l fhir:Coverage/coverage1001 ;
    fhir:reference [ fhir:v "Coverage/coverage1001" ]     ]
      ] ) ; #
      fhir:item ( [
    fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    fhir:revenue [
          ( fhir:coding [
    fhir:system [
    fhir:v "https://www.nubc.org/CodeSystem/RevenueCodes"^^xsd:anyURI ;
    fhir:l <https://www.nubc.org/CodeSystem/RevenueCodes>         ] ;
    fhir:code [ fhir:v "0611" ] ;
    fhir:display [ fhir:v "Magnetic Resonance Technology (MRT) - Brain/brain stem" ]       ] )     ] ;
    fhir:productOrService [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ;
    fhir:l <http://www.ama-assn.org/go/cpt>         ] ;
    fhir:code [ fhir:v "70551" ] ;
    fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ]       ] )     ] ;
        ( fhir:modifier [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ;
    fhir:l <http://www.ama-assn.org/go/cpt>         ] ;
    fhir:code [ fhir:v "70551" ] ;
    fhir:display [ fhir:v "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ]       ] )     ] ) ;
    fhir:serviced [
    a fhir:Date ;
    fhir:v "2022-01-01"^^xsd:date     ] ;
    fhir:net [
    fhir:value [ fhir:v "200"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]     ] ;
        ( fhir:adjudication [
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt>         ] ;
    fhir:value [
    a fhir:CodeableConcept ;
              ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/medical-management-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/medical-management-type>             ] ;
    fhir:code [ fhir:v "concurrent-review" ] ;
    fhir:display [ fhir:v "Concurrent Review" ]           ] )         ]       ] ) ;
    fhir:category [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS>           ] ;
    fhir:code [ fhir:v "medicalmanagement" ] ;
    fhir:display [ fhir:v "Medical Management" ]         ] )       ]     ] )
      ] ) ; #
      fhir:adjudication ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt>       ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/medical-management-type"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/medical-management-type>           ] ;
    fhir:code [ fhir:v "concurrent-review" ] ;
    fhir:display [ fhir:v "Concurrent Review" ]         ] )       ]     ] ) ;
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS>         ] ;
    fhir:code [ fhir:v "medicalmanagement" ] ;
    fhir:display [ fhir:v "Medical Management" ]       ] )     ]
      ] [
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/adjudication>         ] ;
    fhir:code [ fhir:v "submitted" ] ;
    fhir:display [ fhir:v "Submitted Amount" ]       ] )     ]
      ] [
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS>         ] ;
    fhir:code [ fhir:v "memberliability" ] ;
    fhir:display [ fhir:v "Member Liability" ]       ] )     ]
      ] ) ; #
      fhir:total ( [
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/adjudication>         ] ;
    fhir:version [ fhir:v "1.0.1" ] ;
    fhir:code [ fhir:v "submitted" ] ;
    fhir:display [ fhir:v "Submitted Amount" ]       ] )     ] ;
    fhir:amount [
    fhir:value [ fhir:v "200"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS>         ] ;
    fhir:code [ fhir:v "memberliability" ] ;
    fhir:display [ fhir:v "Member liability" ]       ] )     ] ;
    fhir:amount [
    fhir:value [ fhir:v "20"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] [
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/adjudication>         ] ;
    fhir:version [ fhir:v "1.0.1" ] ;
    fhir:code [ fhir:v "eligible" ] ;
    fhir:display [ fhir:v "Eligible Amount" ]       ] )     ] ;
    fhir:amount [
    fhir:value [ fhir:v "190"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]     ]
      ] ) ; #
      fhir:processNote ( [
        ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass>       ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS>           ] ;
    fhir:code [ fhir:v "disclaimer" ] ;
    fhir:display [ fhir:v "Disclaimer" ]         ] )       ]     ] ) ;
    fhir:text [ fhir:v "processNote disclaimer text" ]
      ] ) ; #
      fhir:benefitPeriod [
    fhir:start [ fhir:v "2022-01-01"^^xsd:date ] ;
    fhir:end [ fhir:v "2023-01-01"^^xsd:date ]
      ] ; #
      fhir:benefitBalance ( [
    fhir:category [
          ( fhir:coding [
    fhir:system [
    fhir:v "https://x12.org/codes/service-type-codes"^^xsd:anyURI ;
    fhir:l <https://x12.org/codes/service-type-codes>         ] ;
    fhir:code [ fhir:v "1" ] ;
    fhir:display [ fhir:v "Medical Care" ]       ] ) ;
    fhir:text [ fhir:v "Medical Care" ]     ] ;
    fhir:unit [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/benefit-unit"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/benefit-unit>         ] ;
    fhir:code [ fhir:v "individual" ]       ] )     ] ;
    fhir:term [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/benefit-term"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/benefit-term>         ] ;
    fhir:code [ fhir:v "annual" ]       ] )     ] ;
        ( fhir:financial [
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit>         ] ;
    fhir:value [
    a fhir:Money ;
    fhir:value [ fhir:v "0"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]         ]       ] ) ;
    fhir:type [
            ( fhir:coding [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType>           ] ;
    fhir:code [ fhir:v "allowed" ]         ] )       ] ;
    fhir:allowed [
    a fhir:Money ;
    fhir:value [ fhir:v "1"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]       ] ;
    fhir:used [
    a fhir:Money ;
    fhir:value [ fhir:v "1"^^xsd:decimal ] ;
    fhir:currency [ fhir:v "USD" ]       ]     ] )
      ] ) . #