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 Bundle: PCT-GFE-Bundle-Prof-1

Profile: PCT GFE Bundle

Bundle PCT-GFE-Bundle-Prof-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-MRI

Resource Claim:

> Profile: PCT Good Faith Estimate Summary

> status: Active

> type: Estimate Summary

> use: Predetermination

> patient: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> billablePeriod: 2021-10-31 --> (ongoing)

> created: 2021-10-05

> insurer: Organization Umbrella Insurance Company

> provider: ?rref?

> priority: Normal

> ### Diagnoses

> - | Sequence | Diagnosis[x] | Type
> * | 1 | Unspecified focal traumatic brain injury | Principal Diagnosis

> ### Insurances

> - | Sequence | Focal | Coverage
> * | 1 | true | Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

> ### Totals

> - | Value | Currency
> * | 200 | USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI

Resource Claim:

> 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
> * | 1 | Unspecified focal traumatic brain injury | Principal Diagnosis

> ### 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 | USD

> > ### Nets

> > - | Value | Currency
> > * | 200 | USD

> ### Totals

> - | Value | Currency
> * | 200 | USD

Entry 3 - fullUrl = http://example.org/fhir/Practitioner/Submitter-Practitioner-1

Resource Practitioner:

> Profile: PCT Practitioner

> identifier: United States National Provider Identifier/9941339100, Electronic Transmitter Identification Number/ETIN-20020001

> active: true

> name: Nora Ologist

> telecom: ph: 860-547-3301(Work), csender@GFEServiceHelp.com

Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001

Resource Organization:

> Profile: PCT Organization

> identifier: Electronic Transmitter Identification Number/ETIN-3200002

> active: true

> type: Payer

> name: Umbrella Insurance Company

> ### Contacts

> - | Telecom | Address
> * | ph: 860-547-5001(Work) | 680 Asylum Street Hartford CT 06155 US

Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001

Resource Patient:

> Eve Betterhalf female, DoB: 1955-07-23 ( `http://example.com/identifiers/patient`/1001)

> Marital Status: | unmarried
> Contact Details: | ph: 781-949-4949(MOBILE) 222 Burlington Road, Bedford MA 01730
> Language: | English (United States) (preferred)

Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001

Resource Coverage:

> Profile: PCT Coverage

> Extension Definition for Coverage.kind for Version 5.0: insurance

> status: Active

> subscriberId: PFP123450000

> beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)

> relationship: Self

> period: 2021-01-01 --> 2022-01-01

> ### Classes

> - | Type | Value | Name
> * | Plan | Premim Family Plus | Premim Family Plus Plan

> ### CostToBeneficiaries

> - | Type | Value[x]
> * | Copay Percentage | 20