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

## Example Bundle: PCT-GFE-Packet-Prof-1

Document Details

Profile: PCT GFE Packet

Final Document at 2025-01-10 11:01:00+0500 by Organization Umbrella Insurance Company, Practitioner Nora Ologist for Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

Document Subject

Eve Betterhalf female, DoB: 1955-07-23 ( `http://example.com/identifiers/patient`/1001)

Marital Status: | unmarried
Contact Details: | ph: 781-949-4949(MOBILE) 222 Burlington Road, Bedford MA 01730
Language: | English (United States) (preferred)

Document Content

## Coverage Section

Generated Narrative: Coverage coverage1001

Profile: PCT Coverage

Extension Definition for Coverage.kind for Version 5.0: insurance

status: Active

subscriberId: PFP123450000

beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

relationship: Self

period: 2021-01-01 --> 2022-01-01

payor: Organization Umbrella Insurance Company

### Classes

- | Type | Value | Name
* | Plan | Premim Family Plus | Premim Family Plus Plan

### CostToBeneficiaries

- | Type | Value[x]
* | Copay Percentage | 20

## GFE Section

Generated Narrative: Claim PCT-GFE-Summary-MRI

Profile: PCT Good Faith Estimate Summary

status: Active

type: Estimate Summary

use: Predetermination

patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

billablePeriod: 2021-10-31 --> (ongoing)

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: ?rref?

priority: Normal

### Diagnoses

- | Sequence | Diagnosis[x] | Type | PackageCode
* | 1 | Unspecified focal traumatic brain injury | Principal Diagnosis | Head trauma - concussion

### Insurances

- | Sequence | Focal | Coverage
* | 1 | true | Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

### Totals

- | Value | Currency
* | 200 | United States dollar

## GFE Section

Generated Narrative: PCT-GFE-Missing-Bundle-1

patient: Eve Betterhalf Female, DoB: 1955-07-23 (http://example.com/identifiers/patient#1001)

coverage: Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01

organization: Umbrella Insurance Company

### Requested Services

- device request: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

## Additional Resources Included in Document

Entry 2 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

> Eve Betterhalf female, DoB: 1955-07-23 ( `http://example.com/identifiers/patient`/1001)

> Marital Status: | unmarried
> Contact Details: | ph: 781-949-4949(MOBILE) 222 Burlington Road, Bedford MA 01730
> Language: | English (United States) (preferred)

Entry 3 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

> Profile: PCT Coverage

> Extension Definition for Coverage.kind for Version 5.0: insurance

> status: Active

> subscriberId: PFP123450000

> beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> relationship: Self

> period: 2021-01-01 --> 2022-01-01

> ### Classes

> - | Type | Value | Name
> * | Plan | Premim Family Plus | Premim Family Plus Plan

> ### CostToBeneficiaries

> - | Type | Value[x]
> * | Copay Percentage | 20

Entry 4 - fullUrl = http://example.org/fhir/Practitioner/Submitter-Practitioner-1

Resource Practitioner:

> Profile: PCT Practitioner

> identifier: United States National Provider Identifier/9941339100, Electronic Transmitter Identification Number/ETIN-20020001

> active: true

> name: Nora Ologist

> telecom: ph: 860-547-3301(Work), csender@GFEServiceHelp.com

Entry 5 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

> Profile: PCT Organization

> identifier: Electronic Transmitter Identification Number/ETIN-3200002

> active: true

> type: Payer

> name: Umbrella Insurance Company

> ### Contacts

> - | Telecom | Address
> * | ph: 860-547-5001(Work) | 680 Asylum Street Hartford CT 06155 US

Entry 6 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Bundle-Prof-1

Resource Bundle:

> Profile: PCT GFE Bundle

> Bundle PCT-GFE-Bundle-Prof-1 of type collection

> Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-MRI

> Resource Claim:

> > Profile: PCT Good Faith Estimate Summary

> > status: Active

> > type: Estimate Summary

> > use: Predetermination

> > patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> > billablePeriod: 2021-10-31 --> (ongoing)

> > created: 2021-10-05

> > insurer: Organization Umbrella Insurance Company

> > provider: ?rref?

> > priority: Normal

> > ### Diagnoses

> > - | Sequence | Diagnosis[x] | Type
> > * | 1 | Unspecified focal traumatic brain injury | Principal Diagnosis

> > ### Insurances

> > - | Sequence | Focal | Coverage
> > * | 1 | true | Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

> > ### Totals

> > - | Value | Currency
> > * | 200 | USD

> Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI

> Resource Claim:

> > Profile: PCT Good Faith Estimate Professional

> > ProviderEventMethodology: EEMM1022

> > > GFEServiceLinkingInfo

> > > - linkingIdentifier: `http://example.org/Claim/identifiers`/223452-2342-2435-008001
> > > - plannedPeriodOfService: 2021-10-31

> > identifier: Placer Identifier/GFEProviderAssignedID0002

> > status: Active

> > type: Professional

> > use: Predetermination

> > patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> > created: 2021-10-05

> > insurer: Organization Umbrella Insurance Company

> > provider: Practitioner Nora Ologist

> > priority: Normal

> > ### Payees

> > - | Type
> > * | Provider

> > referral: Referral Number

> > ### Diagnoses

> > - | Sequence | Diagnosis[x] | Type
> > * | 1 | Unspecified focal traumatic brain injury | Principal Diagnosis

> > ### Insurances

> > - | Sequence | Focal | Coverage
> > * | 1 | true | Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

> > > item

> > > Service Description: Imaging

> > > GFEBillingProviderLineItemCtrlNum: GFEBillingProviderLineItemCtrlNum-0001

> > > sequence: 1

> > > productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

> > > modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

> > > serviced: 2021-10-31

> > > location: Inpatient Hospital

> > > quantity: 1

> > > ### UnitPrices

> > > - | Value | Currency
> > > * | 200 | USD

> > > ### Nets

> > > - | Value | Currency
> > > * | 200 | USD

> > ### Totals

> > - | Value | Currency
> > * | 200 | USD

> Entry 3 - fullUrl = http://example.org/fhir/Practitioner/Submitter-Practitioner-1

> Resource Practitioner:

> > Profile: PCT Practitioner

> > identifier: United States National Provider Identifier/9941339100, Electronic Transmitter Identification Number/ETIN-20020001

> > active: true

> > name: Nora Ologist

> > telecom: ph: 860-547-3301(Work), csender@GFEServiceHelp.com

> Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001

> Resource Organization:

> > Profile: PCT Organization

> > identifier: Electronic Transmitter Identification Number/ETIN-3200002

> > active: true

> > type: Payer

> > name: Umbrella Insurance Company

> > ### Contacts

> > - | Telecom | Address
> > * | ph: 860-547-5001(Work) | 680 Asylum Street Hartford CT 06155 US

> Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001

> Resource Patient:

> > Eve Betterhalf female, DoB: 1955-07-23 ( `http://example.com/identifiers/patient`/1001)

> > Marital Status: | unmarried
> > Contact Details: | ph: 781-949-4949(MOBILE) 222 Burlington Road, Bedford MA 01730
> > Language: | English (United States) (preferred)

> Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001

> Resource Coverage:

> > Profile: PCT Coverage

> > Extension Definition for Coverage.kind for Version 5.0: insurance

> > status: Active

> > subscriberId: PFP123450000

> > beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> > relationship: Self

> > period: 2021-01-01 --> 2022-01-01

> > ### Classes

> > - | Type | Value | Name
> > * | Plan | Premim Family Plus | Premim Family Plus Plan

> > ### CostToBeneficiaries

> > - | Type | Value[x]
> > * | Copay Percentage | 20

Entry 7 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1

Resource Bundle:

> Profile: PCT GFE Missing Bundle

> Bundle PCT-GFE-Missing-Bundle-1 of type collection

> Entry 1 - fullUrl = http://example.org/fhir/Organization/org1002

> Resource Organization:

> > Profile: PCT Organization

> > identifier: United States National Provider Identifier/9941339100, Tax ID number/TAX-3211001

> > active: true

> > type: Healthcare Provider

> > name: Boston Radiology Center

> > ### Contacts

> > - | Telecom | Address
> > * | ph: 781-232-3200(Work) | 32 Fruit Street Boston MA 02114 US

> Entry 2 - fullUrl = http://example.org/fhir/Patient/patient1001

> Resource Patient:

> > Eve Betterhalf female, DoB: 1955-07-23 ( `http://example.com/identifiers/patient`/1001)

> > Marital Status: | unmarried
> > Contact Details: | ph: 781-949-4949(MOBILE) 222 Burlington Road, Bedford MA 01730
> > Language: | English (United States) (preferred)

> Entry 3 - fullUrl = http://example.org/fhir/Coverage/coverage1001

> Resource Coverage:

> > Profile: PCT Coverage

> > Extension Definition for Coverage.kind for Version 5.0: insurance

> > status: Active

> > subscriberId: PFP123450000

> > beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> > relationship: Self

> > period: 2021-01-01 --> 2022-01-01

> > ### Classes

> > - | Type | Value | Name
> > * | Plan | Premim Family Plus | Premim Family Plus Plan

> > ### CostToBeneficiaries

> > - | Type | Value[x]
> > * | Copay Percentage | 20

> Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001

> Resource Organization:

> > Profile: PCT Organization

> > identifier: Electronic Transmitter Identification Number/ETIN-3200002

> > active: true

> > type: Payer

> > name: Umbrella Insurance Company

> > ### Contacts

> > - | Telecom | Address
> > * | ph: 860-547-5001(Work) | 680 Asylum Street Hartford CT 06155 US

> Entry 5 - fullUrl = http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1

> Resource DeviceRequest:

> > Profile: PCT GFE DeviceRequest

> > status: Active

> > intent: Proposal

> > subject: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)