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 ExplanationOfBenefit: PCT-AEOB-1

Page standards status: Informative

Profile: PCT Advanced EOB

GFE Reference: Bundle: identifier = http://example.com/identifiers/bundle#59688475-2324-3242-23473847; type = collection; timestamp = 2021-11-09 11:01:00+0500

Service Description: Example service

In Network Provider Options Link: http://example.org/out-of-network.html

identifier: Unique Claim Identifier/?ngen-9?

status: Active

type: Institutional

use: Predetermination

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

created: 2021-10-12

insurer: Organization Umbrella Insurance Company

provider: Organization Boston Radiology Center

priority: Normal

claim: Identifier: `http://example.com/identifiers/bundle`/59688475-2324-3242-23473847

outcome: Processing Complete

### Insurances

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

> item

> sequence: 1

> revenue: Magnetic Resonance Technology (MRT) - Brain/brain stem

> 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: 2022-01-01

> ### Nets

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

> ### Adjudications

> - | Extension | Category
> * |  | Medical Management

### Adjudications

- | Extension | Category
* |  | Medical Management
* |  | Submitted Amount
* |  | Member Liability

> total

> category: Submitted Amount

> ### Amounts

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

> total

> category: Member liability

> ### Amounts

> - | Value | Currency
> * | 20 | United States dollar

> total

> category: Eligible Amount

> ### Amounts

> - | Value | Currency
> * | 190 | United States dollar

### ProcessNotes

- | Extension | Text
* |  | processNote disclaimer text

benefitPeriod: 2022-01-01 --> 2023-01-01

> benefitBalance

> category: Medical Care

> unit: Individual

> term: Annual

> ### Financials

> - | Extension | Type | Allowed[x] | Used[x]
> * |  | Allowed | $1.00 (USD) | $1.00 (USD)