Patient Cost Transparency Implementation Guide
2.0.0 - STU 2
Patient Cost Transparency Implementation Guide
2.0.0 - 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 2.0.0 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
<Bundle xmlns="http://hl7.org/fhir">
<id value="PCT-GFE-Packet-Inst-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-packet"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-2347384711"/>
</identifier>
<type value="document"/>
<timestamp value="2024-03-29T11:01:00+05:00"/>
<entry id="PCT-GFE-Composition-Inst-1">
<fullUrl
value="http://example.org/fhir/Composition/PCT-GFE-Composition-Inst-1"/>
<resource>
<Composition>
<id value="PCT-GFE-Composition-Inst-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-composition"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Composition_PCT-GFE-Composition-Inst-1"> </a><p class="res-header-id"><b>Generated Narrative: Composition PCT-GFE-Composition-Inst-1</b></p><a name="PCT-GFE-Composition-Inst-1"> </a><a name="hcPCT-GFE-Composition-Inst-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-gfe-composition.html">PCT GFE Composition</a></p></div><p><b>Request Initiation Time</b>: 2025-01-08 09:01:00+0500</p><p><b>RequestOriginationType</b>: <span title="Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFERequestTypeCSTemporaryTrialUse nonscheduled-request}">Nonscheduled Service Request</span></p><blockquote><p><b>GFEServiceLinkingInfo</b></p><ul><li>linkingIdentifier: <code>http://example.org/Claim/identifiers</code>/223452-2342-2435-008002</li></ul></blockquote><p><b>identifier</b>: <code>http://www.example.org/identifiers/composition</code>/019283476</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 111480-0}">Good faith estimate</span></p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse estimate}">Estimation Packet</span></p><p><b>date</b>: 2025-01-10 11:01:00+0500</p><p><b>author</b>: </p><ul><li><a href="Organization-org1001.html">Organization Umbrella Insurance Company</a></li><li><a href="Organization-Submitter-Org-1.html">Organization GFE Service Help INC.</a></li></ul><p><b>title</b>: Institutional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10</p></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestInitiationTime">
<valueInstant value="2025-01-08T09:01:00+05:00"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestOriginationType">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTGFERequestTypeCSTemporaryTrialUse"/>
<code value="nonscheduled-request"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
<extension url="linkingIdentifier">
<valueIdentifier>
<system value="http://example.org/Claim/identifiers"/>
<value value="223452-2342-2435-008002"/>
</valueIdentifier>
</extension>
</extension>
<identifier>
<system value="http://www.example.org/identifiers/composition"/>
<value value="019283476"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="111480-0"/>
<display value="Good faith estimate"/>
</coding>
</type>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse"/>
<code value="estimate"/>
</coding>
</category>
<subject>🔗
<reference value="Patient/patient1001"/>
</subject>
<date value="2025-01-10T11:01:00+05:00"/>
<author>🔗
<reference value="Organization/org1001"/>
</author>
<author>🔗
<reference value="Organization/Submitter-Org-1"/>
</author>
<title
value="Institutional Good Faith Estimate Packet for Eve Betterhalf - 2025-01-10"/>
<section>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection"/>
<code value="coverage-section"/>
</coding>
</code>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Coverage selfpaycoverage2001</b></p><a name="selfpaycoverage2001"/><a name="hcselfpaycoverage2001"/><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-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: self-pay</p><p><b>Self-Pay Declared</b>: true</p><p><b>status</b>: Active</p><p><b>subscriberId</b>: Absent because : not-applicable</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span></p><p><b>payor</b>: <a href="Patient-patient1001.html">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p></div>
</text>
<entry>🔗
<reference value="Coverage/coverage1001"/>
</entry>
</section>
<section>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection"/>
<code value="gfe-section"/>
</coding>
</code>
<author>🔗
<reference value="Organization/Submitter-Org-1"/>
</author>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim PCT-GFE-Institutional-1</b></p><a name="PCT-GFE-Institutional-1"/><a name="hcPCT-GFE-Institutional-1"/><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><p><b>GFEDisclaimer</b>: For estimation purposes only</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><ul><li>linkingIdentifier: <code>http://example.org/Claim/identifiers</code>/223452-2342-2435-008001</li><li>plannedPeriodOfService: 2021-10-31</li></ul></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0001</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>: 2021-10-05</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 011X}">Hospital Inpatient (Part A)</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 --> 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>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>: 2021-10-31</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>200</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>200</td><td>United States dollar</td></tr></table></div>
</text>
<entry>🔗
<reference value="Bundle/PCT-GFE-Bundle-Inst-1"/>
</entry>
</section>
<section>
<code>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection"/>
<code value="gfe-section"/>
</coding>
</code>
<author>🔗
<reference value="Organization/org1001"/>
</author>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: PCT-GFE-Missing-Bundle-1</b></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>coverage</b>: <a href="Patient-patient1001.html">Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01</a></p><p><b>organization</b>: <a href="Organization-org1001.html">Umbrella Insurance Company</a></p><h3>Requested Services</h3><ul><li><b>device request</b>: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT</li></ul></div>
</text>
<entry>🔗
<reference value="Bundle/PCT-GFE-Missing-Bundle-1"/>
</entry>
</section>
</Composition>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_patient1001"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_coverage1001"> </a><p class="res-header-id"><b>Generated Narrative: Coverage coverage1001</b></p><a name="coverage1001"> </a><a name="hccoverage1001"> </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-coverage.html">PCT Coverage</a></p></div><p><b>Extension Definition for Coverage.kind for Version 5.0</b>: insurance</p><p><b>status</b>: Active</p><p><b>subscriberId</b>: PFP123450000</p><p><b>beneficiary</b>: <a href="Patient-patient1001.html">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}">Self</span></p><p><b>period</b>: 2021-01-01 --> 2022-01-01</p><p><b>payor</b>: <a href="Organization-org1001.html">Organization Umbrella Insurance Company</a></p><h3>Classes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value</b></td><td><b>Name</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}">Plan</span></td><td>Premim Family Plus</td><td>Premim Family Plus Plan</td></tr></table><h3>CostToBeneficiaries</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Type</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type copaypct}">Copay Percentage</span></td><td>20</td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/Submitter-Org-1"/>
<resource>
<Organization>
<id value="Submitter-Org-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_Submitter-Org-1"> </a><p class="res-header-id"><b>Generated Narrative: Organization Submitter-Org-1</b></p><a name="Submitter-Org-1"> </a><a name="hcSubmitter-Org-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-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-10010301</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type bus}">Non-Healthcare Business or Corporation</span></p><p><b>name</b>: GFE Service Help INC.</p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title="Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType GFERELATED}">GFE-related</span></p><p><b>name</b>: Clara Sender</p><p><b>telecom</b>: ph: 781-632-3209(Work), <a href="mailto:csender@GFEServiceHelp.com">csender@GFEServiceHelp.com</a></p></blockquote></div>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-10010301"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="bus"/>
</coding>
</type>
<name value="GFE Service Help INC."/>
<contact>
<purpose>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType"/>
<code value="GFERELATED"/>
</coding>
</purpose>
<name>
<text value="Clara Sender"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-632-3209"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="csender@GFEServiceHelp.com"/>
<use value="work"/>
</telecom>
</contact>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_org1001"> </a><p class="res-header-id"><b>Generated Narrative: Organization org1001</b></p><a name="org1001"> </a><a name="hcorg1001"> </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-organization.html">PCT Organization</a></p></div><p><b>identifier</b>: Electronic Transmitter Identification Number/ETIN-3200002</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type pay}">Payer</span></p><p><b>name</b>: Umbrella Insurance Company</p><p><b>telecom</b>: ph: 860-547-5001(Work)</p><p><b>address</b>: 680 Asylum Street Hartford CT 06155 US </p></div>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1"/>
<resource>
<Bundle>
<id value="PCT-GFE-Bundle-Inst-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-23473847"/>
</identifier>
<type value="collection"/>
<timestamp value="2021-11-09T11:01:00+05:00"/>
<entry>
<fullUrl value="http://example.org/fhir/Claim/PCT-GFE-Summary-1"/>
<resource>
<Claim>
<id value="PCT-GFE-Summary-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary"/>
</meta>
<status value="active"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse"/>
<code value="estimate-summary"/>
<display value="Estimate Summary"/>
</coding>
</type>
<use value="predetermination"/>
<patient>🔗
<reference value="Patient/patient1001"/>
</patient>
<billablePeriod>
<start value="2021-10-31"/>
<end value="2021-10-31"/>
</billablePeriod>
<created value="2021-10-05"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>
<extension
url="http://hl7.org/fhir/StructureDefinition/data-absent-reason">
<valueCode value="not-applicable"/>
</extension>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display
value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Claim/PCT-GFE-Institutional-1"/>
<resource>
<Claim>
<id value="PCT-GFE-Institutional-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional"/>
</meta>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology">
<valueString value="EEMM1021"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer">
<valueString value="For estimation purposes only"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo">
<extension url="linkingIdentifier">
<valueIdentifier>
<system value="http://example.org/Claim/identifiers"/>
<value value="223452-2342-2435-008001"/>
</valueIdentifier>
</extension>
<extension url="plannedPeriodOfService">
<valueDate value="2021-10-31"/>
</extension>
</extension>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PLAC"/>
<display value="Placer Identifier"/>
</coding>
</type>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<value value="GFEProviderAssignedID0001"/>
</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="2021-10-05"/>
<insurer>🔗
<reference value="Organization/org1001"/>
</insurer>
<provider>🔗
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy">
<valueCodeableConcept>
<coding>
<system value="http://nucc.org/provider-taxonomy"/>
<code value="2085D0003X"/>
<display
value="Diagnostic Neuroimaging (Radiology) Physician"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling">
<valueBoolean value="true"/>
</extension>
<reference value="Organization/Submitter-Org-1"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<payee>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/payeetype"/>
<code value="provider"/>
</coding>
</type>
</payee>
<referral>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber">
<valueString value="REF12022002-121"/>
</extension>
<display value="Referral Number"/>
</referral>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType"/>
<code value="typeofbill"/>
</coding>
</category>
<code>
<coding>
<system
value="https://www.nubc.org/CodeSystem/TypeOfBill"/>
<code value="011X"/>
<display value="Hospital Inpatient (Part A)"/>
</coding>
</code>
</supportingInfo>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="S06.30"/>
<display
value="Unspecified focal traumatic brain injury"/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/diagnosistype"/>
<code value="principal"/>
</coding>
</type>
<packageCode>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
<code value="400"/>
<display value="Head trauma - concussion"/>
</coding>
</packageCode>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/coverage1001"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription">
<valueString value="Imaging"/>
</extension>
<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="2021-10-31"/>
<quantity>
<value value="1"/>
</quantity>
<net>
<value value="200"/>
<currency value="USD"/>
</net>
</item>
<total>
<value value="200"/>
<currency value="USD"/>
</total>
</Claim>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Organization/Submitter-Org-1"/>
<resource>
<Organization>
<id value="Submitter-Org-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-10010301"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="bus"/>
</coding>
</type>
<name value="GFE Service Help INC."/>
<contact>
<purpose>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType"/>
<code value="GFERELATED"/>
</coding>
</purpose>
<name>
<text value="Clara Sender"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-632-3209"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="csender@GFEServiceHelp.com"/>
<use value="work"/>
</telecom>
</contact>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1"/>
<resource>
<Bundle>
<id value="PCT-GFE-Missing-Bundle-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle"/>
</meta>
<identifier>
<system value="http://example.com/identifiers/bundle"/>
<value value="59688475-2324-3242-2347384376"/>
</identifier>
<type value="collection"/>
<timestamp value="2024-03-27T11:01:00+05:00"/>
<entry>
<fullUrl value="http://example.org/fhir/Organization/org1002"/>
<resource>
<Organization>
<id value="org1002"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="9941339100"/>
</identifier>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="TAX"/>
</coding>
</type>
<system value="urn:oid:2.16.840.1.113883.4.4"/>
<value value="TAX-3211001"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Boston Radiology Center"/>
<telecom>
<system value="phone"/>
<value value="781-232-3200"/>
<use value="work"/>
</telecom>
<address>
<line value="32 Fruit Street"/>
<city value="Boston"/>
<state value="MA"/>
<postalCode value="02114"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/patient1001"/>
<resource>
<Patient>
<id value="patient1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b>Eve Betterhalf</b> female, DoB: 1955-07-23 ( <code>http://example.com/identifiers/patient</code>/1001)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-MaritalStatus U}">unmarried</span></td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Details:</td><td colspan="3"><ul><li>ph: 781-949-4949(MOBILE)</li><li>222 Burlington Road, Bedford MA 01730</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Languages spoken">Language:</td><td colspan="3"><span title="Codes: {urn:ietf:bcp:47 en-US}">English (United States)</span> (preferred)</td></tr></table></div>
</text>
<identifier>
<system value="http://example.com/identifiers/patient"/>
<value value="1001"/>
</identifier>
<name>
<text value="Eve Betterhalf"/>
<family value="Betterhalf"/>
<given value="Eve"/>
</name>
<telecom>
<system value="phone"/>
<value value="781-949-4949"/>
<use value="mobile"/>
</telecom>
<gender value="female"/>
<birthDate value="1955-07-23"/>
<address>
<text value="222 Burlington Road, Bedford MA 01730"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-MaritalStatus"/>
<code value="U"/>
<display value="unmarried"/>
</coding>
</maritalStatus>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en-US"/>
<display value="English (United States)"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/coverage1001"/>
<resource>
<Coverage>
<id value="coverage1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage"/>
</meta>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind">
<valueCode value="insurance"/>
</extension>
<status value="active"/>
<subscriberId value="PFP123450000"/>
<beneficiary>🔗
<reference value="Patient/patient1001"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
<display value="Self"/>
</coding>
</relationship>
<period>
<start value="2021-01-01"/>
<end value="2022-01-01"/>
</period>
<payor>🔗
<reference value="Organization/org1001"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Premim Family Plus"/>
<name value="Premim Family Plus Plan"/>
</class>
<costToBeneficiary>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="copaypct"/>
<display value="Copay Percentage"/>
</coding>
</type>
<valueQuantity>
<value value="20"/>
</valueQuantity>
</costToBeneficiary>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/org1001"/>
<resource>
<Organization>
<id value="org1001"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization"/>
</meta>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="ETIN"/>
</coding>
</type>
<value value="ETIN-3200002"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="pay"/>
<display value="Payer"/>
</coding>
</type>
<name value="Umbrella Insurance Company"/>
<telecom>
<system value="phone"/>
<value value="860-547-5001"/>
<use value="work"/>
</telecom>
<address>
<line value="680 Asylum Street"/>
<city value="Hartford"/>
<state value="CT"/>
<postalCode value="06155"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry id="PCT-DeviceRequest-1">
<fullUrl
value="http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1"/>
<resource>
<DeviceRequest>
<id value="PCT-DeviceRequest-1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest"/>
</meta>
<status value="active"/>
<intent value="proposal"/>
<codeCodeableConcept>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="L1820"/>
<display
value="KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT"/>
</coding>
</codeCodeableConcept>
<subject>🔗
<reference value="Patient/patient1001"/>
</subject>
</DeviceRequest>
</resource>
</entry>
</Bundle>
</resource>
</entry>
</Bundle>
IG © 2025+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0 based on FHIR 4.0.1. Generated 2025-09-17
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