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 Claim: PCT-GFE-Professional-MRI

Page standards status: Informative

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 | 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

> 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 | United States dollar

> ### Nets

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

### Totals

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