# PCT Coverage - Patient Cost Transparency Implementation Guide v2.0.1

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **PCT Coverage**

## Resource Profile: PCT Coverage 

| | | |
| :--- | :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage | *Version*:2.0.1 | |
| * Standards status: *[Trial-use](http://hl7.org/fhir/R4/versions.html#std-process) | [Maturity Level](http://hl7.org/fhir/versions.html#maturity): 2 | *Computable Name*:PCTCoverage |
| *Other Identifiers:*OID:2.16.840.1.113883.4.642.40.4.42.8 | | |

 
PCT Coverage is a profile for capturing data that reflect a payer's coverage that was effective as of the proposed date of service or the date of admission of the GFE. 

**Usages:**

* Use this Profile: [PCT AEOB Packet](StructureDefinition-davinci-pct-aeob-packet.md), [PCT GFE Bundle](StructureDefinition-davinci-pct-gfe-bundle.md), [PCT GFE Information Bundle](StructureDefinition-davinci-pct-gfe-information-bundle.md), [PCT GFE Missing Bundle](StructureDefinition-davinci-pct-gfe-missing-bundle.md) and [PCT GFE Packet](StructureDefinition-davinci-pct-gfe-packet.md)
* Refer to this Profile: [PCT Advanced EOB Summary](StructureDefinition-davinci-pct-aeob-summary.md), [PCT Advanced EOB](StructureDefinition-davinci-pct-aeob.md), [PCT GFE Composition](StructureDefinition-davinci-pct-gfe-composition.md), [PCT Good Faith Estimate Institutional](StructureDefinition-davinci-pct-gfe-institutional.md)... Show 2 more, [PCT Good Faith Estimate Professional](StructureDefinition-davinci-pct-gfe-professional.md) and [PCT Good Faith Estimate Summary](StructureDefinition-davinci-pct-gfe-summary.md)
* Examples for this Profile: [Coverage/coverage1001](Coverage-coverage1001.md) and [Coverage/selfpaycoverage2001](Coverage-selfpaycoverage2001.md)
* CapabilityStatements using this Profile: [Patient Cost Transparency Implementation Guide Payer Capability Statement](CapabilityStatement-davinci-pct.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/hl7.fhir.us.davinci-pct|current/StructureDefinition/davinci-pct-coverage)

**Changes since version 1.1.0:**

* The resource metadata has changed (description)

* The data elements list has changed

* One or more text definitions, invariants or bindings have changed

### Formal Views of Profile Content

 [Description of Profiles, Differentials, Snapshots and how the different presentations work](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](StructureDefinition-davinci-pct-coverage.csv), [Excel](StructureDefinition-davinci-pct-coverage.xlsx), [Schematron](StructureDefinition-davinci-pct-coverage.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "davinci-pct-coverage",
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 2
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "fm"
  }],
  "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.40.4.42.8"
  }],
  "version" : "2.0.1",
  "name" : "PCTCoverage",
  "title" : "PCT Coverage",
  "status" : "active",
  "date" : "2026-03-26T13:47:00+00:00",
  "publisher" : "HL7 International / Financial Management",
  "contact" : [{
    "name" : "HL7 International / Financial Management",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/fm"
    },
    {
      "system" : "email",
      "value" : "fmlists@lists.hl7.org"
    }]
  }],
  "description" : "PCT Coverage is a profile for capturing data that reflect a payer's coverage that was effective as of the proposed date of service or the date of admission of the GFE.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US"
    }]
  }],
  "fhirVersion" : "4.0.1",
  "mapping" : [{
    "identity" : "workflow",
    "uri" : "http://hl7.org/fhir/workflow",
    "name" : "Workflow Pattern"
  },
  {
    "identity" : "rim",
    "uri" : "http://hl7.org/v3",
    "name" : "RIM Mapping"
  },
  {
    "identity" : "w5",
    "uri" : "http://hl7.org/fhir/fivews",
    "name" : "FiveWs Pattern Mapping"
  },
  {
    "identity" : "cdanetv4",
    "uri" : "http://www.cda-adc.ca/en/services/cdanet/",
    "name" : "Canadian Dental Association eclaims standard"
  },
  {
    "identity" : "v2",
    "uri" : "http://hl7.org/v2",
    "name" : "HL7 v2 Mapping"
  },
  {
    "identity" : "cpha3pharm",
    "uri" : "http://www.pharmacists.ca/",
    "name" : "Canadian Pharmacy Associaiton eclaims standard"
  }],
  "kind" : "resource",
  "abstract" : false,
  "type" : "Coverage",
  "baseDefinition" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage|7.0.0",
  "derivation" : "constraint",
  "differential" : {
    "element" : [{
      "id" : "Coverage",
      "path" : "Coverage",
      "constraint" : [{
        "key" : "pct-coverage-1",
        "severity" : "error",
        "human" : "Coverage: class element SHALL be present if coverage-0kind is insurance",
        "expression" : "extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()",
        "source" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
      },
      {
        "key" : "pct-coverage-2",
        "severity" : "error",
        "human" : "Coverage: period element SHALL be present if coverage-0kind is insurance",
        "expression" : "extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()",
        "source" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"
      }]
    },
    {
      "id" : "Coverage.extension",
      "path" : "Coverage.extension",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "url"
        }],
        "ordered" : false,
        "rules" : "open"
      },
      "min" : 1
    },
    {
      "id" : "Coverage.extension:coverage-kind",
      "path" : "Coverage.extension",
      "sliceName" : "coverage-kind",
      "min" : 1,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Coverage.extension:coverage-kind.value[x]",
      "path" : "Coverage.extension.value[x]",
      "min" : 1
    },
    {
      "id" : "Coverage.extension:self-pay-declared",
      "path" : "Coverage.extension",
      "sliceName" : "self-pay-declared",
      "min" : 0,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Coverage.type",
      "path" : "Coverage.type",
      "short" : "Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs."
    },
    {
      "id" : "Coverage.subscriber",
      "path" : "Coverage.subscriber",
      "short" : "Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown."
    },
    {
      "id" : "Coverage.subscriber.display",
      "path" : "Coverage.subscriber.display",
      "short" : "Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber's prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference."
    },
    {
      "id" : "Coverage.subscriberId",
      "path" : "Coverage.subscriberId",
      "min" : 1
    },
    {
      "id" : "Coverage.subscriberId.extension",
      "path" : "Coverage.subscriberId.extension",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "url"
        }],
        "ordered" : false,
        "rules" : "open"
      }
    },
    {
      "id" : "Coverage.subscriberId.extension:dataAbsentReason",
      "path" : "Coverage.subscriberId.extension",
      "sliceName" : "dataAbsentReason",
      "min" : 0,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0"]
      }]
    },
    {
      "id" : "Coverage.subscriberId.extension:dataAbsentReason.value[x]",
      "path" : "Coverage.subscriberId.extension.value[x]",
      "short" : "Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured",
      "patternCode" : "not-applicable"
    },
    {
      "id" : "Coverage.beneficiary",
      "path" : "Coverage.beneficiary",
      "short" : "Patient or Plan Beneficiary"
    },
    {
      "id" : "Coverage.payor",
      "path" : "Coverage.payor",
      "short" : "Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization",
        "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0",
        "http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|7.0.0"]
      }]
    },
    {
      "id" : "Coverage.class",
      "path" : "Coverage.class"
    },
    {
      "id" : "Coverage.class.name",
      "path" : "Coverage.class.name",
      "min" : 1
    },
    {
      "id" : "Coverage.class:group",
      "path" : "Coverage.class",
      "sliceName" : "group"
    },
    {
      "id" : "Coverage.class:group.name",
      "path" : "Coverage.class.name",
      "min" : 1
    },
    {
      "id" : "Coverage.class:plan",
      "path" : "Coverage.class",
      "sliceName" : "plan"
    },
    {
      "id" : "Coverage.class:plan.name",
      "path" : "Coverage.class.name",
      "min" : 1
    },
    {
      "id" : "Coverage.costToBeneficiary.type",
      "path" : "Coverage.costToBeneficiary.type",
      "binding" : {
        "strength" : "required",
        "valueSet" : "http://terminology.hl7.org/ValueSet/coverage-copay-type|1.0.1"
      }
    }]
  }
}

```
