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-AEOB-1 - JSON Representation

Page standards status: Informative

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    {
      "resourceType" : "ExplanationOfBenefit",
      "id" : "PCT-AEOB-1",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"
        ]
      },
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-1</b></p><a name=\"PCT-AEOB-1\"> </a><a name=\"hcPCT-AEOB-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-aeob.html\">PCT Advanced EOB</a></p></div><p><b>GFE Reference</b>: <a href=\"Bundle-PCT-GFE-Bundle-Inst-1.html\">Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-23473847; type = collection; timestamp = 2021-11-09 11:01:00+0500</a></p><p><b>Service Description</b>: Example service</p><p><b>In Network Provider Options Link</b>: <a href=\"http://example.org/out-of-network.html\">http://example.org/out-of-network.html</a></p><p><b>identifier</b>: Unique Claim Identifier/?ngen-9?</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</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>: 2021-10-12</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Organization Boston Radiology Center</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>claim</b>: Identifier: <code>http://example.com/identifiers/bundle</code>/59688475-2324-3242-23473847</p><p><b>outcome</b>: Processing Complete</p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</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>sequence</b>: 1</p><p><b>revenue</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0611}\">Magnetic Resonance Technology (MRT) - Brain/brain stem</span></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>: 2022-01-01</p><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><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS medicalmanagement}\">Medical Management</span></td></tr></table></blockquote><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS medicalmanagement}\">Medical Management</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></td></tr><tr><td style=\"display: none\">*</td><td> </td><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member Liability</span></td></tr></table><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</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><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS memberliability}\">Member liability</span></p><h3>Amounts</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>20</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible Amount</span></p><h3>Amounts</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>190</td><td>United States dollar</td></tr></table></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>processNote disclaimer text</td></tr></table><p><b>benefitPeriod</b>: 2022-01-01 --&gt; 2023-01-01</p><blockquote><p><b>benefitBalance</b></p><p><b>category</b>: <span title=\"Codes:{https://x12.org/codes/service-type-codes 1}\">Medical Care</span></p><p><b>unit</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-unit individual}\">Individual</span></p><p><b>term</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-term annual}\">Annual</span></p><h3>Financials</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Type</b></td><td><b>Allowed[x]</b></td><td><b>Used[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType allowed}\">Allowed</span></td><td><span title=\"US Dollar\">$1.00</span> (USD)</td><td><span title=\"US Dollar\">$1.00</span> (USD)</td></tr></table></blockquote></div>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference",
          "valueReference" : {
            🔗 "reference" : "Bundle/PCT-GFE-Bundle-Inst-1"
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription",
          "valueString" : "Example service"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink",
          "valueUrl" : "http://example.org/out-of-network.html"
        }
      ],
      "identifier" : [
        {
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                "code" : "UCID"
              }
            ]
          }
        }
      ],
      "status" : "active",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
            "code" : "institutional",
            "display" : "Institutional"
          }
        ]
      },
      "use" : "predetermination",
      "patient" : {
        🔗 "reference" : "Patient/patient1001"
      },
      "created" : "2021-10-12",
      "insurer" : {
        🔗 "reference" : "Organization/org1001"
      },
      "provider" : {
        🔗 "reference" : "Organization/org1002"
      },
      "priority" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
            "code" : "normal"
          }
        ]
      },
      "claim" : {
        "identifier" : {
          "system" : "http://example.com/identifiers/bundle",
          "value" : "59688475-2324-3242-23473847"
        }
      },
      "outcome" : "complete",
      "insurance" : [
        {
          "focal" : true,
          "coverage" : {
            🔗 "reference" : "Coverage/coverage1001"
          }
        }
      ],
      "item" : [
        {
          "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"
              }
            ]
          },
          "modifier" : [
            {
              "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" : "2022-01-01",
          "net" : {
            "value" : 200,
            "currency" : "USD"
          },
          "adjudication" : [
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "http://terminology.hl7.org/CodeSystem/medical-management-type",
                        "code" : "concurrent-review",
                        "display" : "Concurrent Review"
                      }
                    ]
                  }
                }
              ],
              "category" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "medicalmanagement",
                    "display" : "Medical Management"
                  }
                ]
              }
            }
          ]
        }
      ],
      "adjudication" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://terminology.hl7.org/CodeSystem/medical-management-type",
                    "code" : "concurrent-review",
                    "display" : "Concurrent Review"
                  }
                ]
              }
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "medicalmanagement",
                "display" : "Medical Management"
              }
            ]
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted",
                "display" : "Submitted Amount"
              }
            ]
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "memberliability",
                "display" : "Member Liability"
              }
            ]
          }
        }
      ],
      "total" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "version" : "1.0.1",
                "code" : "submitted",
                "display" : "Submitted Amount"
              }
            ]
          },
          "amount" : {
            "value" : 200,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "memberliability",
                "display" : "Member liability"
              }
            ]
          },
          "amount" : {
            "value" : 20,
            "currency" : "USD"
          }
        },
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "version" : "1.0.1",
                "code" : "eligible",
                "display" : "Eligible Amount"
              }
            ]
          },
          "amount" : {
            "value" : 190,
            "currency" : "USD"
          }
        }
      ],
      "processNote" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS",
                    "code" : "disclaimer",
                    "display" : "Disclaimer"
                  }
                ]
              }
            }
          ],
          "text" : "processNote disclaimer text"
        }
      ],
      "benefitPeriod" : {
        "start" : "2022-01-01",
        "end" : "2023-01-01"
      },
      "benefitBalance" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "https://x12.org/codes/service-type-codes",
                "code" : "1",
                "display" : "Medical Care"
              }
            ],
            "text" : "Medical Care"
          },
          "unit" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/benefit-unit",
                "code" : "individual"
              }
            ]
          },
          "term" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/benefit-term",
                "code" : "annual"
              }
            ]
          },
          "financial" : [
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit",
                  "valueMoney" : {
                    "value" : 0,
                    "currency" : "USD"
                  }
                }
              ],
              "type" : {
                "coding" : [
                  {
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
                    "code" : "allowed"
                  }
                ]
              },
              "allowedMoney" : {
                "value" : 1,
                "currency" : "USD"
              },
              "usedMoney" : {
                "value" : 1,
                "currency" : "USD"
              }
            }
          ]
        }
      ]
    }