# PCT-GFE-Institutional-MRI - Patient Cost Transparency Implementation Guide v2.0.1

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **PCT-GFE-Institutional-MRI**

## Example Claim: PCT-GFE-Institutional-MRI

| |
| :--- |
| *Page standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) |

Profile: [PCT Good Faith Estimate Institutional](StructureDefinition-davinci-pct-gfe-institutional.md)

**ProviderEventMethodology**: EEMM1021

> **GFEServiceLinkingInfo**
* linkingIdentifier: `http://example.org/Claim/identifiers`/223452-2342-2435-008002
* plannedPeriodOfService: 2022-02-02

**identifier**: Placer Identifier/GFEProviderAssignedID0001MRI

**status**: Active

**type**: Institutional

**use**: Predetermination

**patient**: [Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)](Patient-patient1001.md)

**created**: 2022-02-02

**insurer**: [Organization Umbrella Insurance Company](Organization-org1001.md)

**provider**: [Organization GFE Service Help INC.](Organization-Submitter-Org-1.md)

**priority**: Normal

### Payees

| | |
| :--- | :--- |
| - | **Type** |
| * | Provider |

**referral**: Referral Number

### SupportingInfos

| | | | |
| :--- | :--- | :--- | :--- |
| - | **Sequence** | **Category** | **Code** |
| * | 1 | Type of Bill | example-bill-type |

### 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](Coverage-coverage1001.md) |

> **item****Service Description**: Imaging**sequence**: 1**revenue**: Magnetic Resonance Technology (MRT) - Brain/brain stem**productOrService**: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material**serviced**: 2022-02-02**quantity**: 1

### Nets

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 266 | United States dollar |


### Totals

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 266 | United States dollar |



## Resource Content

```json
{
  "resourceType" : "Claim",
  "id" : "PCT-GFE-Institutional-MRI",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"]
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology",
    "valueString" : "EEMM1021"
  },
  {
    "extension" : [{
      "url" : "linkingIdentifier",
      "valueIdentifier" : {
        "system" : "http://example.org/Claim/identifiers",
        "value" : "223452-2342-2435-008002"
      }
    },
    {
      "url" : "plannedPeriodOfService",
      "valueDate" : "2022-02-02"
    }],
    "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo"
  }],
  "identifier" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
        "code" : "PLAC",
        "display" : "Placer Identifier"
      }]
    },
    "value" : "GFEProviderAssignedID0001MRI"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "institutional",
      "display" : "Institutional"
    }]
  },
  "use" : "predetermination",
  "patient" : {
    "reference" : "Patient/patient1001"
  },
  "created" : "2022-02-02",
  "insurer" : {
    "reference" : "Organization/org1001"
  },
  "provider" : {
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://nucc.org/provider-taxonomy",
          "code" : "2085D0003X",
          "display" : "Diagnostic Neuroimaging (Radiology) Physician"
        }]
      }
    }],
    "reference" : "Organization/Submitter-Org-1"
  },
  "priority" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
      "code" : "normal"
    }]
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
        "code" : "provider"
      }]
    }
  },
  "referral" : {
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber",
      "valueString" : "REF12022002-122"
    }],
    "display" : "Referral Number"
  },
  "supportingInfo" : [{
    "sequence" : 1,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType",
        "code" : "typeofbill"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "https://www.nubc.org/CodeSystem/TypeOfBill",
        "code" : "example-bill-type"
      }]
    }
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/sid/icd-10-cm",
        "code" : "S06.30",
        "display" : "Unspecified focal traumatic brain injury"
      }]
    },
    "type" : [{
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype",
        "code" : "principal"
      }]
    }],
    "packageCode" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup",
        "code" : "400",
        "display" : "Head trauma - concussion"
      }]
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/coverage1001"
    }
  }],
  "item" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
      "valueString" : "Imaging"
    }],
    "sequence" : 1,
    "revenue" : {
      "coding" : [{
        "system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
        "code" : "0611",
        "display" : "Magnetic Resonance Technology (MRT) - Brain/brain stem"
      }]
    },
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.ama-assn.org/go/cpt",
        "code" : "70551",
        "display" : "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
      }]
    },
    "servicedDate" : "2022-02-02",
    "quantity" : {
      "value" : 1
    },
    "net" : {
      "value" : 266,
      "currency" : "USD"
    }
  }],
  "total" : {
    "value" : 266,
    "currency" : "USD"
  }
}

```
