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-GFE-Institutional-1 - XML Representation

Page standards status: Informative

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    <Claim xmlns="http://hl7.org/fhir">
      <id value="PCT-GFE-Institutional-1"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim PCT-GFE-Institutional-1</b></p><a name="PCT-GFE-Institutional-1"> </a><a name="hcPCT-GFE-Institutional-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-gfe-institutional.html">PCT Good Faith Estimate Institutional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1021</p><p><b>GFEDisclaimer</b>: For estimation purposes only</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><ul><li>linkingIdentifier: <code>http://example.org/Claim/identifiers</code>/223452-2342-2435-008001</li><li>plannedPeriodOfService: 2021-10-31</li></ul></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001</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>: 2021-10-05</p><p><b>insurer</b>: <a href="Organization-org1001.html">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href="Organization-Submitter-Org-1.html">Organization GFE Service Help INC.</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>Payees</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}">Provider</span></td></tr></table><p><b>referral</b>: Referral Number</p><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType typeofbill}">Type of Bill</span></td><td><span title="Codes:{https://www.nubc.org/CodeSystem/TypeOfBill 011X}">Hospital Inpatient (Part A)</span></td></tr></table><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/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; 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>Service Description</b>: Imaging</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>: 2021-10-31</p><p><b>quantity</b>: 1</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></blockquote><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>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
        <valueString value="EEMM1021"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer">
        <valueString value="For estimation purposes only"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
        <extension url="linkingIdentifier">
          <valueIdentifier>
            <system value="http://example.org/Claim/identifiers"/>
            <value value="223452-2342-2435-008001"/>
          </valueIdentifier>
        </extension>
        <extension url="plannedPeriodOfService">
          <valueDate value="2021-10-31"/>
        </extension>
      </extension>
      <identifier>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
            <code value="PLAC"/>
            <display value="Placer Identifier"/>
          </coding>
        </type>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <value value="GFEProviderAssignedID0001"/>
      </identifier>
      <status value="active"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
          <code value="institutional"/>
          <display value="Institutional"/>
        </coding>
      </type>
      <use value="predetermination"/>
      <patient>🔗
        <reference value="Patient/patient1001"/>
      </patient>
      <created value="2021-10-05"/>
      <insurer>🔗
        <reference value="Organization/org1001"/>
      </insurer>
      <provider>🔗
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
          <valueCodeableConcept>
            <coding>
              <system value="http://nucc.org/provider-taxonomy"/>
              <code value="2085D0003X"/>
              <display value="Diagnostic Neuroimaging (Radiology) Physician"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling">
          <valueBoolean value="true"/>
        </extension>
        <reference value="Organization/Submitter-Org-1"/>
      </provider>
      <priority>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
          <code value="normal"/>
        </coding>
      </priority>
      <payee>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
            <code value="provider"/>
          </coding>
        </type>
      </payee>
      <referral>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
          <valueString value="REF12022002-121"/>
        </extension>
        <display value="Referral Number"/>
      </referral>
      <supportingInfo>
        <sequence value="1"/>
        <category>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType"/>
            <code value="typeofbill"/>
          </coding>
        </category>
        <code>
          <coding>
            <system value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
            <code value="011X"/>
            <display value="Hospital Inpatient (Part A)"/>
          </coding>
        </code>
      </supportingInfo>
      <diagnosis>
        <sequence value="1"/>
        <diagnosisCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
            <code value="S06.30"/>
            <display value="Unspecified focal traumatic brain injury"/>
          </coding>
        </diagnosisCodeableConcept>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/diagnosistype"/>
            <code value="principal"/>
          </coding>
        </type>
        <packageCode>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
            <code value="400"/>
            <display value="Head trauma - concussion"/>
          </coding>
        </packageCode>
      </diagnosis>
      <insurance>
        <sequence value="1"/>
        <focal value="true"/>
        <coverage>🔗
          <reference value="Coverage/coverage1001"/>
        </coverage>
      </insurance>
      <item>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
          <valueString value="Imaging"/>
        </extension>
        <sequence value="1"/>
        <revenue>
          <coding>
            <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
            <code value="0611"/>
            <display
                     value="Magnetic Resonance Technology (MRT) - Brain/brain stem"/>
          </coding>
        </revenue>
        <productOrService>
          <coding>
            <system value="http://www.ama-assn.org/go/cpt"/>
            <code value="70551"/>
            <display
                     value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
          </coding>
        </productOrService>
        <modifier>
          <coding>
            <system value="http://www.ama-assn.org/go/cpt"/>
            <code value="70551"/>
            <display
                     value="Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"/>
          </coding>
        </modifier>
        <servicedDate value="2021-10-31"/>
        <quantity>
          <value value="1"/>
        </quantity>
        <net>
          <value value="200"/>
          <currency value="USD"/>
        </net>
      </item>
      <total>
        <value value="200"/>
        <currency value="USD"/>
      </total>
    </Claim>