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-Institutional-MRI - JSON Representation

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    {
      "resourceType" : "Claim",
      "id" : "PCT-GFE-Institutional-MRI",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"
        ]
      },
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PCT-GFE-Institutional-MRI</b></p><a name=\"PCT-GFE-Institutional-MRI\"> </a><a name=\"hcPCT-GFE-Institutional-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-institutional.html\">PCT Good Faith Estimate Institutional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1021</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><ul><li>linkingIdentifier: <code>http://example.org/Claim/identifiers</code>/223452-2342-2435-008002</li><li>plannedPeriodOfService: 2022-02-02</li></ul></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001MRI</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>: 2022-02-02</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Organization Umbrella Insurance Company</a></p><p><b>provider</b>: <a href=\"Organization-Submitter-Org-1.html\">Organization GFE Service Help INC.</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>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Code</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType typeofbill}\">Type of Bill</span></td><td><span title=\"Codes:{https://www.nubc.org/CodeSystem/TypeOfBill example-bill-type}\">example-bill-type</span></td></tr></table><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>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>serviced</b>: 2022-02-02</p><p><b>quantity</b>: 1</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>266</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>266</td><td>United States dollar</td></tr></table></div>"
      },
      "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"
      }
    }