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 - XML Representation

Page standards status: Informative

Raw xml | Download

    <ExplanationOfBenefit xmlns="http://hl7.org/fhir">
      <id value="PCT-AEOB-1"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob"/>
      </meta>
      <text>
        <status value="extensions"/>
        <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>
      </text>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference">
        <valueReference>🔗
          <reference value="Bundle/PCT-GFE-Bundle-Inst-1"/>
        </valueReference>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
        <valueString value="Example service"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink">
        <valueUrl value="http://example.org/out-of-network.html"/>
      </extension>
      <identifier>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
            <code value="UCID"/>
          </coding>
        </type>
      </identifier>
      <status value="active"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
          <code value="institutional"/>
          <display value="Institutional"/>
        </coding>
      </type>
      <use value="predetermination"/>
      <patient>🔗
        <reference value="Patient/patient1001"/>
      </patient>
      <created value="2021-10-12"/>
      <insurer>🔗
        <reference value="Organization/org1001"/>
      </insurer>
      <provider>🔗
        <reference value="Organization/org1002"/>
      </provider>
      <priority>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
          <code value="normal"/>
        </coding>
      </priority>
      <claim>
        <identifier>
          <system value="http://example.com/identifiers/bundle"/>
          <value value="59688475-2324-3242-23473847"/>
        </identifier>
      </claim>
      <outcome value="complete"/>
      <insurance>
        <focal value="true"/>
        <coverage>🔗
          <reference value="Coverage/coverage1001"/>
        </coverage>
      </insurance>
      <item>
        <sequence value="1"/>
        <revenue>
          <coding>
            <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
            <code value="0611"/>
            <display
                     value="Magnetic Resonance Technology (MRT) - Brain/brain stem"/>
          </coding>
        </revenue>
        <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="2022-01-01"/>
        <net>
          <value value="200"/>
          <currency value="USD"/>
        </net>
        <adjudication>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/medical-management-type"/>
                <code value="concurrent-review"/>
                <display value="Concurrent Review"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
              <code value="medicalmanagement"/>
              <display value="Medical Management"/>
            </coding>
          </category>
        </adjudication>
      </item>
      <adjudication>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/medical-management-type"/>
              <code value="concurrent-review"/>
              <display value="Concurrent Review"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <category>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
            <code value="medicalmanagement"/>
            <display value="Medical Management"/>
          </coding>
        </category>
      </adjudication>
      <adjudication>
        <category>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
            <code value="submitted"/>
            <display value="Submitted Amount"/>
          </coding>
        </category>
      </adjudication>
      <adjudication>
        <category>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
            <code value="memberliability"/>
            <display value="Member Liability"/>
          </coding>
        </category>
      </adjudication>
      <total>
        <category>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
            <version value="1.0.1"/>
            <code value="submitted"/>
            <display value="Submitted Amount"/>
          </coding>
        </category>
        <amount>
          <value value="200"/>
          <currency value="USD"/>
        </amount>
      </total>
      <total>
        <category>
          <coding>
            <system
                    value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS"/>
            <code value="memberliability"/>
            <display value="Member liability"/>
          </coding>
        </category>
        <amount>
          <value value="20"/>
          <currency value="USD"/>
        </amount>
      </total>
      <total>
        <category>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
            <version value="1.0.1"/>
            <code value="eligible"/>
            <display value="Eligible Amount"/>
          </coding>
        </category>
        <amount>
          <value value="190"/>
          <currency value="USD"/>
        </amount>
      </total>
      <processNote>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS"/>
              <code value="disclaimer"/>
              <display value="Disclaimer"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <text value="processNote disclaimer text"/>
      </processNote>
      <benefitPeriod>
        <start value="2022-01-01"/>
        <end value="2023-01-01"/>
      </benefitPeriod>
      <benefitBalance>
        <category>
          <coding>
            <system value="https://x12.org/codes/service-type-codes"/>
            <code value="1"/>
            <display value="Medical Care"/>
          </coding>
          <text value="Medical Care"/>
        </category>
        <unit>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
            <code value="individual"/>
          </coding>
        </unit>
        <term>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/benefit-term"/>
            <code value="annual"/>
          </coding>
        </term>
        <financial>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit">
            <valueMoney>
              <value value="0"/>
              <currency value="USD"/>
            </valueMoney>
          </extension>
          <type>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"/>
              <code value="allowed"/>
            </coding>
          </type>
          <allowedMoney>
            <value value="1"/>
            <currency value="USD"/>
          </allowedMoney>
          <usedMoney>
            <value value="1"/>
            <currency value="USD"/>
          </usedMoney>
        </financial>
      </benefitBalance>
    </ExplanationOfBenefit>