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-Bundle-Prof-1 - XML Representation

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    <Bundle xmlns="http://hl7.org/fhir">
      <id value="PCT-GFE-Bundle-Prof-1"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
      </meta>
      <identifier>
        <system value="http://example.com/identifiers/bundle"/>
        <value value="59688475-2324-3242-23473847"/>
      </identifier>
      <type value="collection"/>
      <timestamp value="2021-11-09T11:01:00+05:00"/>
      <entry>
        <fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Summary-MRI"/>
        <resource>
          <Claim>
            <id value="PCT-GFE-Summary-MRI"/>
            <meta>
              <profile
                       value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"/>
            </meta>
            <text>
              <status value="generated"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Claim_PCT-GFE-Summary-MRI"> </a><p class="res-header-id"><b>Generated Narrative: Claim PCT-GFE-Summary-MRI</b></p><a name="PCT-GFE-Summary-MRI"> </a><a name="hcPCT-GFE-Summary-MRI"> </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-summary.html">PCT Good Faith Estimate  Summary</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}">Estimate Summary</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>billablePeriod</b>: 2021-10-31 --&gt; (ongoing)</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>: ?rref?</p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><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><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>
            <status value="active"/>
            <type>
              <coding>
                <system
                        value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
                <code value="estimate-summary"/>
                <display value="Estimate Summary"/>
              </coding>
            </type>
            <use value="predetermination"/>
            <patient>🔗
              <reference value="Patient/patient1001"/>
            </patient>
            <billablePeriod>
              <start value="2021-10-31"/>
            </billablePeriod>
            <created value="2021-10-05"/>
            <insurer>🔗
              <reference value="Organization/org1001"/>
            </insurer>
            <provider>
              <extension
                         url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
                <valueCode value="not-applicable"/>
              </extension>
            </provider>
            <priority>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/processpriority"/>
                <code value="normal"/>
              </coding>
            </priority>
            <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>
            <total>
              <value value="200"/>
              <currency value="USD"/>
            </total>
          </Claim>
        </resource>
      </entry>
      <entry>
        <fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Professional-MRI"/>
        <resource>
          <Claim>
            <id value="PCT-GFE-Professional-MRI"/>
            <meta>
              <profile
                       value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional"/>
            </meta>
            <text>
              <status value="extensions"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Claim_PCT-GFE-Professional-MRI"> </a><p class="res-header-id"><b>Generated Narrative: Claim PCT-GFE-Professional-MRI</b></p><a name="PCT-GFE-Professional-MRI"> </a><a name="hcPCT-GFE-Professional-MRI"> </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-professional.html">PCT Good Faith Estimate Professional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1022</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/GFEProviderAssignedID0002</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</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="Practitioner-Submitter-Practitioner-1.html">Practitioner Nora Ologist</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>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>GFEBillingProviderLineItemCtrlNum</b>: GFEBillingProviderLineItemCtrlNum-0001</p><p><b>sequence</b>: 1</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>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">Inpatient Hospital</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</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><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="EEMM1022"/>
            </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="GFEProviderAssignedID0002"/>
            </identifier>
            <status value="active"/>
            <type>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
                <code value="professional"/>
                <display value="Professional"/>
              </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>
              <reference value="Practitioner/Submitter-Practitioner-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="REF12022002-122"/>
              </extension>
              <display value="Referral Number"/>
            </referral>
            <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>
              <extension
                         url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum">
                <valueIdentifier>
                  <value value="GFEBillingProviderLineItemCtrlNum-0001"/>
                </valueIdentifier>
              </extension>
              <sequence value="1"/>
              <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"/>
              <locationCodeableConcept>
                <coding>
                  <system
                          value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
                  <code value="21"/>
                  <display value="Inpatient Hospital"/>
                </coding>
              </locationCodeableConcept>
              <quantity>
                <value value="1"/>
              </quantity>
              <unitPrice>
                <value value="200"/>
                <currency value="USD"/>
              </unitPrice>
              <net>
                <value value="200"/>
                <currency value="USD"/>
              </net>
            </item>
            <total>
              <value value="200"/>
              <currency value="USD"/>
            </total>
          </Claim>
        </resource>
      </entry>
      <entry>
        <fullUrl
                 value="http://example.org/fhir/Practitioner/Submitter-Practitioner-1"/>
        <resource>
          <Practitioner>
            <id value="Submitter-Practitioner-1"/>
            <meta>
              <profile
                       value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner"/>
            </meta>
            <text>
              <status value="generated"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_Submitter-Practitioner-1"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner Submitter-Practitioner-1</b></p><a name="Submitter-Practitioner-1"> </a><a name="hcSubmitter-Practitioner-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-practitioner.html">PCT Practitioner</a></p></div><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.5.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/9941339100, Electronic Transmitter Identification Number/ETIN-20020001</p><p><b>active</b>: true</p><p><b>name</b>: Nora Ologist</p><p><b>telecom</b>: ph: 860-547-3301(Work), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></p></div>
            </text>
            <identifier>
              <system value="http://hl7.org/fhir/sid/us-npi"/>
              <value value="9941339100"/>
            </identifier>
            <identifier>
              <type>
                <coding>
                  <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                  <code value="ETIN"/>
                </coding>
              </type>
              <system value="http://example.com/us-etin"/>
              <value value="ETIN-20020001"/>
            </identifier>
            <active value="true"/>
            <name>
              <text value="Nora Ologist"/>
              <family value="Ologist"/>
              <given value="Nora"/>
            </name>
            <telecom>
              <system value="phone"/>
              <value value="860-547-3301"/>
              <use value="work"/>
            </telecom>
            <telecom>
              <system value="email"/>
              <value value="csender@GFEServiceHelp.com"/>
              <use value="work"/>
            </telecom>
          </Practitioner>
        </resource>
      </entry>
      <entry>
        <fullUrl value="http://example.org/fhir/Organization/org1001"/>
        <resource>
          <Organization>
            <id value="org1001"/>
            <meta>
              <profile
                       value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
            </meta>
            <text>
              <status value="generated"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_org1001"> </a><p class="res-header-id"><b>Generated Narrative: Organization org1001</b></p><a name="org1001"> </a><a name="hcorg1001"> </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-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type pay}">Payer</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(Work)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US </p></div>
            </text>
            <identifier>
              <type>
                <coding>
                  <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
                  <code value="ETIN"/>
                </coding>
              </type>
              <value value="ETIN-3200002"/>
            </identifier>
            <active value="true"/>
            <type>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/organization-type"/>
                <code value="pay"/>
                <display value="Payer"/>
              </coding>
            </type>
            <name value="Umbrella Insurance Company"/>
            <telecom>
              <system value="phone"/>
              <value value="860-547-5001"/>
              <use value="work"/>
            </telecom>
            <address>
              <line value="680 Asylum Street"/>
              <city value="Hartford"/>
              <state value="CT"/>
              <postalCode value="06155"/>
              <country value="US"/>
            </address>
          </Organization>
        </resource>
      </entry>
      <entry>
        <fullUrl value="http://example.org/fhir/Patient/patient1001"/>
        <resource>
          <Patient>
            <id value="patient1001"/>
            <meta>
              <profile
                       value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"/>
            </meta>
            <text>
              <status value="additional"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_patient1001"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
            </text>
            <identifier>
              <system value="http://example.com/identifiers/patient"/>
              <value value="1001"/>
            </identifier>
            <name>
              <text value="Eve Betterhalf"/>
              <family value="Betterhalf"/>
              <given value="Eve"/>
            </name>
            <telecom>
              <system value="phone"/>
              <value value="781-949-4949"/>
              <use value="mobile"/>
            </telecom>
            <gender value="female"/>
            <birthDate value="1955-07-23"/>
            <address>
              <text value="222 Burlington Road, Bedford MA 01730"/>
            </address>
            <maritalStatus>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
                <code value="U"/>
                <display value="unmarried"/>
              </coding>
            </maritalStatus>
            <communication>
              <language>
                <coding>
                  <system value="urn:ietf:bcp:47"/>
                  <code value="en-US"/>
                  <display value="English (United States)"/>
                </coding>
              </language>
              <preferred value="true"/>
            </communication>
          </Patient>
        </resource>
      </entry>
      <entry>
        <fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
        <resource>
          <Coverage>
            <id value="coverage1001"/>
            <meta>
              <profile
                       value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
            </meta>
            <text>
              <status value="extensions"/>
              <div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_coverage1001"> </a><p class="res-header-id"><b>Generated Narrative: Coverage coverage1001</b></p><a name="coverage1001"> </a><a name="hccoverage1001"> </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-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: Active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span></p><p><b>period</b>: 2021-01-01 --&gt; 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization Umbrella Insurance Company</a></p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}">Plan</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type copaypct}">Copay Percentage</span></td><td>20</td></tr></table></div>
            </text>
            <extension
                       url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
              <valueCode value="insurance"/>
            </extension>
            <status value="active"/>
            <subscriberId value="PFP123450000"/>
            <beneficiary>🔗
              <reference value="Patient/patient1001"/>
            </beneficiary>
            <relationship>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
                <code value="self"/>
                <display value="Self"/>
              </coding>
            </relationship>
            <period>
              <start value="2021-01-01"/>
              <end value="2022-01-01"/>
            </period>
            <payor>🔗
              <reference value="Organization/org1001"/>
            </payor>
            <class>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                  <code value="plan"/>
                  <display value="Plan"/>
                </coding>
              </type>
              <value value="Premim Family Plus"/>
              <name value="Premim Family Plus Plan"/>
            </class>
            <costToBeneficiary>
              <type>
                <coding>
                  <system
                          value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
                  <code value="copaypct"/>
                  <display value="Copay Percentage"/>
                </coding>
              </type>
              <valueQuantity>
                <value value="20"/>
              </valueQuantity>
            </costToBeneficiary>
          </Coverage>
        </resource>
      </entry>
    </Bundle>