Patient Cost Transparency Implementation Guide
2.0.2 - STU 2
Patient Cost Transparency Implementation Guide
2.0.2 - 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 2.0.2 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
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/rdf#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/Bundle/PCT-AEOB-Packet-1> a fhir:Bundle ; fhir:nodeRole fhir:treeRoot ; fhir:Resource.id [ fhir:value "PCT-AEOB-Packet-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-packet" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-packet> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:Bundle.identifier [ fhir:Identifier.system [ fhir:value "http://example.com/identifiers/bundle" ] ; fhir:Identifier.value [ fhir:value "59688475-2324-3242-1234568" ] ] ; fhir:Bundle.type [ fhir:value "document"] ; fhir:Bundle.timestamp [ fhir:value "2025-01-10T11:01:00+05:00"^^xsd:dateTime] ; fhir:Bundle.entry [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Composition/PCT-AEOB-Composition-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Composition/PCT-AEOB-Composition-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Patient/patient1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Patient/patient1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Coverage/coverage1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Coverage/coverage1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/org1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/org1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/Submitter-Org-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/Submitter-Org-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/org1002" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/org1002> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1> ] . <http://example.org/fhir/Composition/PCT-AEOB-Composition-1> a fhir:Composition ; fhir:Resource.id [ fhir:value "PCT-AEOB-Composition-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-composition" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-composition> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Composition_PCT-AEOB-Composition-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Composition PCT-AEOB-Composition-1</b></p><a name=\"PCT-AEOB-Composition-1\"> </a><a name=\"hcPCT-AEOB-Composition-1\"> </a><div style=\"display: inline-block; background-color: #fbffeb; 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-composition.html\">PCT AEOB Composition</a></p></div><p><b>Request Initiation Time</b>: 2025-01-08 09:01:00+0500</p><p><b>identifier</b>: <code>http://www.example.org/identifiers/composition</code>/019283475</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 111479-2}\">Advanced explanation of benefits</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\">Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)</a></li><li><a href=\"Organization-Submitter-Org-1.html\">GFE Service Help INC. (Non-Healthcare Business or Corporation) (Electronic Transmitter Identification Number: ETIN-10010301)</a></li></ul><p><b>title</b>: Advanced Explanation of Benefit Packet for Eve Betterhalf - 2025-01-10</p></div>" ] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestInitiationTime" ] ; fhir:Extension.valueInstant [ fhir:value "2025-01-08T09:01:00+05:00"^^xsd:dateTime ] ] ; fhir:Composition.identifier [ fhir:Identifier.system [ fhir:value "http://www.example.org/identifiers/composition" ] ; fhir:Identifier.value [ fhir:value "019283475" ] ] ; fhir:Composition.status [ fhir:value "final"] ; fhir:Composition.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; a loinc:111479-2 ; fhir:Coding.system [ fhir:value "http://loinc.org" ] ; fhir:Coding.code [ fhir:value "111479-2" ] ; fhir:Coding.display [ fhir:value "Advanced explanation of benefits" ] ] ] ; fhir:Composition.category [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse" ] ; fhir:Coding.code [ fhir:value "estimate" ] ] ] ; fhir:Composition.subject [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] ; fhir:Composition.date [ fhir:value "2025-01-10T11:01:00+05:00"^^xsd:dateTime] ; fhir:Composition.author [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ], [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/Submitter-Org-1> ; fhir:Reference.reference [ fhir:value "Organization/Submitter-Org-1" ] ] ; fhir:Composition.title [ fhir:value "Advanced Explanation of Benefit Packet for Eve Betterhalf - 2025-01-10"] ; fhir:Composition.section [ fhir:index -1 ; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection" ] ; fhir:Coding.code [ fhir:value "aeob-summary-section" ] ] ] ; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1</b></p><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-summary.html\">PCT Advanced EOB Summary</a></p></div><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>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</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>billablePeriod</b>: 2022-01-01 --> 2022-01-01</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>: ?rref?</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 --> 2022-01-01</a></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 --> 2022-01-01</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>" ] ; fhir:Composition.section.entry [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1> ; fhir:Reference.reference [ fhir:value "ExplanationOfBenefit/PCT-AEOB-Summary-1" ] ] ], [ fhir:index -1 ; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection" ] ; fhir:Coding.code [ fhir:value "aeob-section" ] ] ] ; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1</b></p><a name=\"PCT-AEOB-Summary-1\"/><a name=\"hcPCT-AEOB-Summary-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-aeob-summary.html\">PCT Advanced EOB Summary</a></p></div><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>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</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>billablePeriod</b>: 2022-01-01 --> 2022-01-01</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>: ?rref?</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 --> 2022-01-01</a></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 --> 2022-01-01</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>" ] ; fhir:Composition.section.entry [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/ExplanationOfBenefit/PCT-AEOB-1> ; fhir:Reference.reference [ fhir:value "ExplanationOfBenefit/PCT-AEOB-1" ] ] ], [ fhir:index -1 ; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection" ] ; fhir:Coding.code [ fhir:value "gfe-section" ] ] ] ; fhir:Composition.section.author [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/Submitter-Org-1> ; fhir:Reference.reference [ fhir:value "Organization/Submitter-Org-1" ] ] ; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<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>" ] ; fhir:Composition.section.entry [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1> ; fhir:Reference.reference [ fhir:value "Bundle/PCT-GFE-Bundle-Inst-1" ] ] ], [ fhir:index -1 ; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentSection" ] ; fhir:Coding.code [ fhir:value "gfe-section" ] ] ] ; fhir:Composition.section.author [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/Submitter-Org-1> ; fhir:Reference.reference [ fhir:value "Organization/Submitter-Org-1" ] ] ; fhir:Composition.section.entry [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1> ; fhir:Reference.reference [ fhir:value "Bundle/PCT-GFE-Missing-Bundle-1" ] ] ] . <http://hl7.org/fhir/Patient/patient1001> a fhir:Patient . <http://hl7.org/fhir/Organization/org1001> a fhir:Organization . <http://hl7.org/fhir/Organization/Submitter-Org-1> a fhir:Organization . <http://hl7.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1> a fhir:ExplanationOfBenefit . <http://hl7.org/fhir/ExplanationOfBenefit/PCT-AEOB-1> a fhir:ExplanationOfBenefit . <http://hl7.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1> a fhir:Bundle . <http://hl7.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1> a fhir:Bundle . <http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-Summary-1> a fhir:ExplanationOfBenefit ; fhir:Resource.id [ fhir:value "PCT-AEOB-Summary-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ExplanationOfBenefit_PCT-AEOB-Summary-1\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PCT-AEOB-Summary-1</b></p><a name=\"PCT-AEOB-Summary-1\"> </a><a name=\"hcPCT-AEOB-Summary-1\"> </a><div style=\"display: inline-block; background-color: #fbffeb; 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-summary.html\">PCT Advanced EOB Summary</a></p></div><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>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse estimate-summary}\">Estimate Summary</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>billablePeriod</b>: 2022-01-01 --> 2022-01-01</p><p><b>created</b>: 2021-10-12</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)</a></p><p><b>provider</b>: ?rref?</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 --> 2022-01-01</a></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 --> 2022-01-01</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>" ] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription" ] ; fhir:Extension.valueString [ fhir:value "Example service" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink" ] ; fhir:Extension.valueUrl [ fhir:value "http://example.org/out-of-network.html" ] ] ; fhir:ExplanationOfBenefit.status [ fhir:value "active"] ; fhir:ExplanationOfBenefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse" ] ; fhir:Coding.code [ fhir:value "estimate-summary" ] ; fhir:Coding.display [ fhir:value "Estimate Summary" ] ] ] ; fhir:ExplanationOfBenefit.use [ fhir:value "predetermination"] ; fhir:ExplanationOfBenefit.patient [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] ; fhir:ExplanationOfBenefit.billablePeriod [ fhir:Period.start [ fhir:value "2022-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2022-01-01"^^xsd:date ] ] ; fhir:ExplanationOfBenefit.created [ fhir:value "2021-10-12"^^xsd:date] ; fhir:ExplanationOfBenefit.insurer [ fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ] ; fhir:ExplanationOfBenefit.provider [ fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "not-applicable" ] ] ] ; fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"] ; fhir:ExplanationOfBenefit.insurance [ fhir:index -1 ; fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ] ; fhir:ExplanationOfBenefit.insurance.coverage [ fhir:link <http://hl7.org/fhir/Coverage/coverage1001> ; fhir:Reference.reference [ fhir:value "Coverage/coverage1001" ] ] ] ; fhir:ExplanationOfBenefit.total [ fhir:index -1 ; fhir:ExplanationOfBenefit.total.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ; fhir:Coding.code [ fhir:value "submitted" ] ; fhir:Coding.display [ fhir:value "Submitted Amount" ] ] ] ; fhir:ExplanationOfBenefit.total.amount [ fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:ExplanationOfBenefit.total.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS" ] ; fhir:Coding.code [ fhir:value "memberliability" ] ; fhir:Coding.display [ fhir:value "Member liability" ] ] ] ; fhir:ExplanationOfBenefit.total.amount [ fhir:Money.value [ fhir:value "20"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:ExplanationOfBenefit.total.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ; fhir:Coding.code [ fhir:value "eligible" ] ; fhir:Coding.display [ fhir:value "Eligible Amount" ] ] ] ; fhir:ExplanationOfBenefit.total.amount [ fhir:Money.value [ fhir:value "190"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ; fhir:ExplanationOfBenefit.processNote [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS" ] ; fhir:Coding.code [ fhir:value "disclaimer" ] ; fhir:Coding.display [ fhir:value "Disclaimer" ] ] ] ] ; fhir:ExplanationOfBenefit.processNote.text [ fhir:value "processNote disclaimer text" ] ] ; fhir:ExplanationOfBenefit.benefitPeriod [ fhir:Period.start [ fhir:value "2022-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2022-01-01"^^xsd:date ] ] ; fhir:ExplanationOfBenefit.benefitBalance [ fhir:index -1 ; fhir:ExplanationOfBenefit.benefitBalance.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "https://x12.org/codes/service-type-codes" ] ; fhir:Coding.code [ fhir:value "1" ] ; fhir:Coding.display [ fhir:value "Medical Care" ] ] ; fhir:CodeableConcept.text [ fhir:value "Medical Care" ] ] ; fhir:ExplanationOfBenefit.benefitBalance.unit [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "individual" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.term [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-term" ] ; fhir:Coding.code [ fhir:value "annual" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit" ] ; fhir:Extension.valueMoney [ fhir:Money.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType" ] ; fhir:Coding.code [ fhir:value "allowed" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ fhir:Money.value [ fhir:value "1"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ fhir:Money.value [ fhir:value "1"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ] . <http://hl7.org/fhir/Coverage/coverage1001> a fhir:Coverage . <http://example.org/fhir/ExplanationOfBenefit/PCT-AEOB-1> a fhir:ExplanationOfBenefit ; fhir:Resource.id [ fhir:value "PCT-AEOB-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ExplanationOfBenefit_PCT-AEOB-1\"> </a><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: #fbffeb; 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/f000fb40-2113-4679-9338-53a9a51e96a9</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\">Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)</a></p><p><b>provider</b>: <a href=\"Organization-org1002.html\">Boston Radiology Center (Healthcare Provider) (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#9941339100)</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 --> 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 --> 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>" ] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference" ] ; fhir:Extension.valueReference [ fhir:link <http://hl7.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1> ; fhir:Reference.reference [ fhir:value "Bundle/PCT-GFE-Bundle-Inst-1" ] ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription" ] ; fhir:Extension.valueString [ fhir:value "Example service" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink" ] ; fhir:Extension.valueUrl [ fhir:value "http://example.org/out-of-network.html" ] ] ; fhir:ExplanationOfBenefit.identifier [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "UCID" ] ] ] ; fhir:Identifier.value [ fhir:value "f000fb40-2113-4679-9338-53a9a51e96a9" ] ] ; fhir:ExplanationOfBenefit.status [ fhir:value "active"] ; fhir:ExplanationOfBenefit.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ] ; fhir:Coding.code [ fhir:value "institutional" ] ; fhir:Coding.display [ fhir:value "Institutional" ] ] ] ; fhir:ExplanationOfBenefit.use [ fhir:value "predetermination"] ; fhir:ExplanationOfBenefit.patient [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] ; fhir:ExplanationOfBenefit.created [ fhir:value "2021-10-12"^^xsd:date] ; fhir:ExplanationOfBenefit.insurer [ fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ] ; fhir:ExplanationOfBenefit.provider [ fhir:link <http://hl7.org/fhir/Organization/org1002> ; fhir:Reference.reference [ fhir:value "Organization/org1002" ] ] ; fhir:ExplanationOfBenefit.priority [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/processpriority" ] ; fhir:Coding.code [ fhir:value "normal" ] ] ] ; fhir:ExplanationOfBenefit.claim [ fhir:Reference.identifier [ fhir:Identifier.system [ fhir:value "http://example.com/identifiers/bundle" ] ; fhir:Identifier.value [ fhir:value "59688475-2324-3242-23473847" ] ] ] ; fhir:ExplanationOfBenefit.outcome [ fhir:value "complete"] ; fhir:ExplanationOfBenefit.insurance [ fhir:index -1 ; fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ] ; fhir:ExplanationOfBenefit.insurance.coverage [ fhir:link <http://hl7.org/fhir/Coverage/coverage1001> ; fhir:Reference.reference [ fhir:value "Coverage/coverage1001" ] ] ] ; fhir:ExplanationOfBenefit.item [ fhir:index -1 ; fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:ExplanationOfBenefit.item.revenue [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "https://www.nubc.org/CodeSystem/RevenueCodes" ] ; fhir:Coding.code [ fhir:value "0611" ] ; fhir:Coding.display [ fhir:value "Magnetic Resonance Technology (MRT) - Brain/brain stem" ] ] ] ; fhir:ExplanationOfBenefit.item.productOrService [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ] ; fhir:Coding.code [ fhir:value "70551" ] ; fhir:Coding.display [ fhir:value "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ] ; fhir:ExplanationOfBenefit.item.modifier [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ] ; fhir:Coding.code [ fhir:value "70551" ] ; fhir:Coding.display [ fhir:value "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ] ; fhir:ExplanationOfBenefit.item.servicedDate [ fhir:value "2022-01-01"^^xsd:date ] ; fhir:ExplanationOfBenefit.item.net [ fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:ExplanationOfBenefit.item.adjudication [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/medical-management-type" ] ; fhir:Coding.code [ fhir:value "concurrent-review" ] ; fhir:Coding.display [ fhir:value "Concurrent Review" ] ] ] ] ; fhir:ExplanationOfBenefit.item.adjudication.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS" ] ; fhir:Coding.code [ fhir:value "medicalmanagement" ] ; fhir:Coding.display [ fhir:value "Medical Management" ] ] ] ] ] ; fhir:ExplanationOfBenefit.adjudication [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/medical-management-type" ] ; fhir:Coding.code [ fhir:value "concurrent-review" ] ; fhir:Coding.display [ fhir:value "Concurrent Review" ] ] ] ] ; fhir:ExplanationOfBenefit.item.adjudication.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS" ] ; fhir:Coding.code [ fhir:value "medicalmanagement" ] ; fhir:Coding.display [ fhir:value "Medical Management" ] ] ] ], [ fhir:index -1 ; fhir:ExplanationOfBenefit.item.adjudication.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ; fhir:Coding.code [ fhir:value "submitted" ] ; fhir:Coding.display [ fhir:value "Submitted Amount" ] ] ] ], [ fhir:index -1 ; fhir:ExplanationOfBenefit.item.adjudication.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS" ] ; fhir:Coding.code [ fhir:value "memberliability" ] ; fhir:Coding.display [ fhir:value "Member Liability" ] ] ] ] ; fhir:ExplanationOfBenefit.total [ fhir:index -1 ; fhir:ExplanationOfBenefit.total.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ; fhir:Coding.code [ fhir:value "submitted" ] ; fhir:Coding.display [ fhir:value "Submitted Amount" ] ] ] ; fhir:ExplanationOfBenefit.total.amount [ fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:ExplanationOfBenefit.total.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS" ] ; fhir:Coding.code [ fhir:value "memberliability" ] ; fhir:Coding.display [ fhir:value "Member liability" ] ] ] ; fhir:ExplanationOfBenefit.total.amount [ fhir:Money.value [ fhir:value "20"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ], [ fhir:index -1 ; fhir:ExplanationOfBenefit.total.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ; fhir:Coding.code [ fhir:value "eligible" ] ; fhir:Coding.display [ fhir:value "Eligible Amount" ] ] ] ; fhir:ExplanationOfBenefit.total.amount [ fhir:Money.value [ fhir:value "190"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ; fhir:ExplanationOfBenefit.processNote [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAEOBProcessNoteCS" ] ; fhir:Coding.code [ fhir:value "disclaimer" ] ; fhir:Coding.display [ fhir:value "Disclaimer" ] ] ] ] ; fhir:ExplanationOfBenefit.processNote.text [ fhir:value "processNote disclaimer text" ] ] ; fhir:ExplanationOfBenefit.benefitPeriod [ fhir:Period.start [ fhir:value "2022-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2023-01-01"^^xsd:date ] ] ; fhir:ExplanationOfBenefit.benefitBalance [ fhir:index -1 ; fhir:ExplanationOfBenefit.benefitBalance.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "https://x12.org/codes/service-type-codes" ] ; fhir:Coding.code [ fhir:value "1" ] ; fhir:Coding.display [ fhir:value "Medical Care" ] ] ; fhir:CodeableConcept.text [ fhir:value "Medical Care" ] ] ; fhir:ExplanationOfBenefit.benefitBalance.unit [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "individual" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.term [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-term" ] ; fhir:Coding.code [ fhir:value "annual" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit" ] ; fhir:Extension.valueMoney [ fhir:Money.value [ fhir:value "0"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType" ] ; fhir:Coding.code [ fhir:value "allowed" ] ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial.allowedMoney [ fhir:Money.value [ fhir:value "1"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:ExplanationOfBenefit.benefitBalance.financial.usedMoney [ fhir:Money.value [ fhir:value "1"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ] . <http://hl7.org/fhir/Organization/org1002> a fhir:Organization . <http://example.org/fhir/Patient/patient1001> a fhir:Patient, fhir:Patient, fhir:Patient ; fhir:Resource.id [ fhir:value "patient1001"], [ fhir:value "patient1001"], [ fhir:value "patient1001"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0> ] ] ; fhir:Resource.language [ fhir:value "en"], [ fhir:value "en"], [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "additional" ] ; fhir:Narrative.div "<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>" ], [ fhir:Narrative.status [ fhir:value "additional" ] ; fhir:Narrative.div "<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>" ], [ fhir:Narrative.status [ fhir:value "additional" ] ; fhir:Narrative.div "<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>" ] ; fhir:Patient.identifier [ fhir:index -1 ; fhir:Identifier.system [ fhir:value "http://example.com/identifiers/patient" ] ; fhir:Identifier.value [ fhir:value "1001" ] ], [ fhir:index -1 ; fhir:Identifier.system [ fhir:value "http://example.com/identifiers/patient" ] ; fhir:Identifier.value [ fhir:value "1001" ] ], [ fhir:index -1 ; fhir:Identifier.system [ fhir:value "http://example.com/identifiers/patient" ] ; fhir:Identifier.value [ fhir:value "1001" ] ] ; fhir:Patient.name [ fhir:index -1 ; fhir:HumanName.text [ fhir:value "Eve Betterhalf" ] ; fhir:HumanName.family [ fhir:value "Betterhalf" ] ; fhir:HumanName.given [ fhir:value "Eve" ; fhir:index -1 ] ], [ fhir:index -1 ; fhir:HumanName.text [ fhir:value "Eve Betterhalf" ] ; fhir:HumanName.family [ fhir:value "Betterhalf" ] ; fhir:HumanName.given [ fhir:value "Eve" ; fhir:index -1 ] ], [ fhir:index -1 ; fhir:HumanName.text [ fhir:value "Eve Betterhalf" ] ; fhir:HumanName.family [ fhir:value "Betterhalf" ] ; fhir:HumanName.given [ fhir:value "Eve" ; fhir:index -1 ] ] ; fhir:Patient.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-949-4949" ] ; fhir:ContactPoint.use [ fhir:value "mobile" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-949-4949" ] ; fhir:ContactPoint.use [ fhir:value "mobile" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-949-4949" ] ; fhir:ContactPoint.use [ fhir:value "mobile" ] ] ; fhir:Patient.gender [ fhir:value "female"], [ fhir:value "female"], [ fhir:value "female"] ; fhir:Patient.birthDate [ fhir:value "1955-07-23"^^xsd:date], [ fhir:value "1955-07-23"^^xsd:date], [ fhir:value "1955-07-23"^^xsd:date] ; fhir:Patient.address [ fhir:index -1 ; fhir:Address.text [ fhir:value "222 Burlington Road, Bedford MA 01730" ] ], [ fhir:index -1 ; fhir:Address.text [ fhir:value "222 Burlington Road, Bedford MA 01730" ] ], [ fhir:index -1 ; fhir:Address.text [ fhir:value "222 Burlington Road, Bedford MA 01730" ] ] ; fhir:Patient.maritalStatus [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus" ] ; fhir:Coding.code [ fhir:value "U" ] ; fhir:Coding.display [ fhir:value "unmarried" ] ] ], [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus" ] ; fhir:Coding.code [ fhir:value "U" ] ; fhir:Coding.display [ fhir:value "unmarried" ] ] ], [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus" ] ; fhir:Coding.code [ fhir:value "U" ] ; fhir:Coding.display [ fhir:value "unmarried" ] ] ] ; fhir:Patient.communication [ fhir:index -1 ; fhir:Patient.communication.language [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ] ; fhir:Coding.code [ fhir:value "en-US" ] ; fhir:Coding.display [ fhir:value "English (United States)" ] ] ] ; fhir:Patient.communication.preferred [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index -1 ; fhir:Patient.communication.language [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ] ; fhir:Coding.code [ fhir:value "en-US" ] ; fhir:Coding.display [ fhir:value "English (United States)" ] ] ] ; fhir:Patient.communication.preferred [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index -1 ; fhir:Patient.communication.language [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "urn:ietf:bcp:47" ] ; fhir:Coding.code [ fhir:value "en-US" ] ; fhir:Coding.display [ fhir:value "English (United States)" ] ] ] ; fhir:Patient.communication.preferred [ fhir:value "true"^^xsd:boolean ] ] . <http://example.org/fhir/Coverage/coverage1001> a fhir:Coverage, fhir:Coverage, fhir:Coverage ; fhir:Resource.id [ fhir:value "coverage1001"], [ fhir:value "coverage1001"], [ fhir:value "coverage1001"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage> ] ] ; fhir:Resource.language [ fhir:value "en"], [ fhir:value "en"], [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "<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: #fbffeb; 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>R5: insurance | self-pay | other (new)</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\">Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)</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>" ] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind" ] ; fhir:Extension.valueCode [ fhir:value "insurance" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind" ] ; fhir:Extension.valueCode [ fhir:value "insurance" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind" ] ; fhir:Extension.valueCode [ fhir:value "insurance" ] ] ; fhir:Coverage.status [ fhir:value "active"], [ fhir:value "active"], [ fhir:value "active"] ; fhir:Coverage.subscriberId [ fhir:value "PFP123450000"], [ fhir:value "PFP123450000"], [ fhir:value "PFP123450000"] ; fhir:Coverage.beneficiary [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ], [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ], [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] ; fhir:Coverage.relationship [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/subscriber-relationship" ] ; fhir:Coding.code [ fhir:value "self" ] ; fhir:Coding.display [ fhir:value "Self" ] ] ], [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/subscriber-relationship" ] ; fhir:Coding.code [ fhir:value "self" ] ; fhir:Coding.display [ fhir:value "Self" ] ] ], [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/subscriber-relationship" ] ; fhir:Coding.code [ fhir:value "self" ] ; fhir:Coding.display [ fhir:value "Self" ] ] ] ; fhir:Coverage.period [ fhir:Period.start [ fhir:value "2021-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2022-01-01"^^xsd:date ] ], [ fhir:Period.start [ fhir:value "2021-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2022-01-01"^^xsd:date ] ], [ fhir:Period.start [ fhir:value "2021-01-01"^^xsd:date ] ; fhir:Period.end [ fhir:value "2022-01-01"^^xsd:date ] ] ; fhir:Coverage.payor [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ], [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ], [ fhir:index -1 ; fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ] ; fhir:Coverage.class [ fhir:index -1 ; fhir:Coverage.class.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ; fhir:Coding.code [ fhir:value "plan" ] ; fhir:Coding.display [ fhir:value "Plan" ] ] ] ; fhir:Coverage.class.value [ fhir:value "Premim Family Plus" ] ; fhir:Coverage.class.name [ fhir:value "Premim Family Plus Plan" ] ], [ fhir:index -1 ; fhir:Coverage.class.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ; fhir:Coding.code [ fhir:value "plan" ] ; fhir:Coding.display [ fhir:value "Plan" ] ] ] ; fhir:Coverage.class.value [ fhir:value "Premim Family Plus" ] ; fhir:Coverage.class.name [ fhir:value "Premim Family Plus Plan" ] ], [ fhir:index -1 ; fhir:Coverage.class.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-class" ] ; fhir:Coding.code [ fhir:value "plan" ] ; fhir:Coding.display [ fhir:value "Plan" ] ] ] ; fhir:Coverage.class.value [ fhir:value "Premim Family Plus" ] ; fhir:Coverage.class.name [ fhir:value "Premim Family Plus Plan" ] ] ; fhir:Coverage.costToBeneficiary [ fhir:index -1 ; fhir:Coverage.costToBeneficiary.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "copaypct" ] ; fhir:Coding.display [ fhir:value "Copay Percentage" ] ] ] ; fhir:Coverage.costToBeneficiary.valueQuantity [ fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ] ] ], [ fhir:index -1 ; fhir:Coverage.costToBeneficiary.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "copaypct" ] ; fhir:Coding.display [ fhir:value "Copay Percentage" ] ] ] ; fhir:Coverage.costToBeneficiary.valueQuantity [ fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ] ] ], [ fhir:index -1 ; fhir:Coverage.costToBeneficiary.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "copaypct" ] ; fhir:Coding.display [ fhir:value "Copay Percentage" ] ] ] ; fhir:Coverage.costToBeneficiary.valueQuantity [ fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ] ] ] . <http://example.org/fhir/Organization/org1001> a fhir:Organization, fhir:Organization, fhir:Organization ; fhir:Resource.id [ fhir:value "org1001"], [ fhir:value "org1001"], [ fhir:value "org1001"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ] ; fhir:Resource.language [ fhir:value "en"], [ fhir:value "en"], [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "<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: #fbffeb; 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 style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"The kind(s) of organization that this is\">Type:</td><td colspan=\"3\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type pay}\">Payer</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the organization\">Contact Detail</td><td colspan=\"3\"><ul><li>ph: 860-547-5001(Work)</li><li>680 Asylum Street Hartford CT 06155 US </li></ul></td></tr></table></div>" ] ; fhir:Organization.identifier [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ETIN" ] ] ] ; fhir:Identifier.value [ fhir:value "ETIN-3200002" ] ], [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ETIN" ] ] ] ; fhir:Identifier.value [ fhir:value "ETIN-3200002" ] ], [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ETIN" ] ] ] ; fhir:Identifier.value [ fhir:value "ETIN-3200002" ] ] ; fhir:Organization.active [ fhir:value "true"^^xsd:boolean], [ fhir:value "true"^^xsd:boolean], [ fhir:value "true"^^xsd:boolean] ; fhir:Organization.type [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "pay" ] ; fhir:Coding.display [ fhir:value "Payer" ] ] ], [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "pay" ] ; fhir:Coding.display [ fhir:value "Payer" ] ] ], [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "pay" ] ; fhir:Coding.display [ fhir:value "Payer" ] ] ] ; fhir:Organization.name [ fhir:value "Umbrella Insurance Company"], [ fhir:value "Umbrella Insurance Company"], [ fhir:value "Umbrella Insurance Company"] ; fhir:Organization.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "860-547-5001" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "860-547-5001" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "860-547-5001" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ] ; fhir:Organization.address [ fhir:index -1 ; fhir:Address.line [ fhir:value "680 Asylum Street" ; fhir:index -1 ] ; fhir:Address.city [ fhir:value "Hartford" ] ; fhir:Address.state [ fhir:value "CT" ] ; fhir:Address.postalCode [ fhir:value "06155" ] ; fhir:Address.country [ fhir:value "US" ] ], [ fhir:index -1 ; fhir:Address.line [ fhir:value "680 Asylum Street" ; fhir:index -1 ] ; fhir:Address.city [ fhir:value "Hartford" ] ; fhir:Address.state [ fhir:value "CT" ] ; fhir:Address.postalCode [ fhir:value "06155" ] ; fhir:Address.country [ fhir:value "US" ] ], [ fhir:index -1 ; fhir:Address.line [ fhir:value "680 Asylum Street" ; fhir:index -1 ] ; fhir:Address.city [ fhir:value "Hartford" ] ; fhir:Address.state [ fhir:value "CT" ] ; fhir:Address.postalCode [ fhir:value "06155" ] ; fhir:Address.country [ fhir:value "US" ] ] . <http://example.org/fhir/Organization/Submitter-Org-1> a fhir:Organization, fhir:Organization ; fhir:Resource.id [ fhir:value "Submitter-Org-1"], [ fhir:value "Submitter-Org-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ] ; fhir:Resource.language [ fhir:value "en"], [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "<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: #fbffeb; 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 style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">GFE Service Help INC. (Non-Healthcare Business or Corporation) (Electronic Transmitter Identification Number: ETIN-10010301)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"The kind(s) of organization that this is\">Type:</td><td colspan=\"3\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type bus}\">Non-Healthcare Business or Corporation</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the organization\">GFE-related:</td><td colspan=\"3\"><ul><li>Clara Sender</li><li>ph: 781-632-3209(Work)</li><li><a href=\"mailto:csender@GFEServiceHelp.com\">csender@GFEServiceHelp.com</a></li></ul></td></tr></table></div>" ] ; fhir:Organization.identifier [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ETIN" ] ] ] ; fhir:Identifier.value [ fhir:value "ETIN-10010301" ] ], [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ETIN" ] ] ] ; fhir:Identifier.value [ fhir:value "ETIN-10010301" ] ] ; fhir:Organization.active [ fhir:value "true"^^xsd:boolean], [ fhir:value "true"^^xsd:boolean] ; fhir:Organization.type [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "bus" ] ] ], [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "bus" ] ] ] ; fhir:Organization.name [ fhir:value "GFE Service Help INC."], [ fhir:value "GFE Service Help INC."] ; fhir:Organization.contact [ fhir:index -1 ; fhir:Organization.contact.purpose [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType" ] ; fhir:Coding.code [ fhir:value "GFERELATED" ] ] ] ; fhir:Organization.contact.name [ fhir:HumanName.text [ fhir:value "Clara Sender" ] ] ; fhir:Organization.contact.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-632-3209" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "email" ] ; fhir:ContactPoint.value [ fhir:value "csender@GFEServiceHelp.com" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ] ], [ fhir:index -1 ; fhir:Organization.contact.purpose [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTOrgContactPurposeType" ] ; fhir:Coding.code [ fhir:value "GFERELATED" ] ] ] ; fhir:Organization.contact.name [ fhir:HumanName.text [ fhir:value "Clara Sender" ] ] ; fhir:Organization.contact.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-632-3209" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "email" ] ; fhir:ContactPoint.value [ fhir:value "csender@GFEServiceHelp.com" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ] ] . <http://example.org/fhir/Organization/org1002> a fhir:Organization, fhir:Organization ; fhir:Resource.id [ fhir:value "org1002"], [ fhir:value "org1002"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ], [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization> ] ] ; fhir:Resource.language [ fhir:value "en"], [ fhir:value "en"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_org1002\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization org1002</b></p><a name=\"org1002\"> </a><a name=\"hcorg1002\"> </a><div style=\"display: inline-block; background-color: #fbffeb; 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 style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Boston Radiology Center (Healthcare Provider) (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#9941339100)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"The kind(s) of organization that this is\">Type:</td><td colspan=\"3\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Other Id (see the one above)\">Other Id:</td><td colspan=\"3\">Tax ID number/TAX-3211001</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the organization\">Contact Detail</td><td colspan=\"3\"><ul><li>ph: 781-232-3200(Work)</li><li>32 Fruit Street Boston MA 02114 US </li></ul></td></tr></table></div>" ] ; fhir:Organization.identifier [ fhir:index -1 ; fhir:Identifier.system [ fhir:value "http://hl7.org/fhir/sid/us-npi" ] ; fhir:Identifier.value [ fhir:value "9941339100" ] ], [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "TAX" ] ] ] ; fhir:Identifier.system [ fhir:value "urn:oid:2.16.840.1.113883.4.4" ] ; fhir:Identifier.value [ fhir:value "TAX-3211001" ] ], [ fhir:index -1 ; fhir:Identifier.system [ fhir:value "http://hl7.org/fhir/sid/us-npi" ] ; fhir:Identifier.value [ fhir:value "9941339100" ] ], [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "TAX" ] ] ] ; fhir:Identifier.system [ fhir:value "urn:oid:2.16.840.1.113883.4.4" ] ; fhir:Identifier.value [ fhir:value "TAX-3211001" ] ] ; fhir:Organization.active [ fhir:value "true"^^xsd:boolean], [ fhir:value "true"^^xsd:boolean] ; fhir:Organization.type [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "prov" ] ; fhir:Coding.display [ fhir:value "Healthcare Provider" ] ] ], [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/organization-type" ] ; fhir:Coding.code [ fhir:value "prov" ] ; fhir:Coding.display [ fhir:value "Healthcare Provider" ] ] ] ; fhir:Organization.name [ fhir:value "Boston Radiology Center"], [ fhir:value "Boston Radiology Center"] ; fhir:Organization.telecom [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-232-3200" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ], [ fhir:index -1 ; fhir:ContactPoint.system [ fhir:value "phone" ] ; fhir:ContactPoint.value [ fhir:value "781-232-3200" ] ; fhir:ContactPoint.use [ fhir:value "work" ] ] ; fhir:Organization.address [ fhir:index -1 ; fhir:Address.line [ fhir:value "32 Fruit Street" ; fhir:index -1 ] ; fhir:Address.city [ fhir:value "Boston" ] ; fhir:Address.state [ fhir:value "MA" ] ; fhir:Address.postalCode [ fhir:value "02114" ] ; fhir:Address.country [ fhir:value "US" ] ], [ fhir:index -1 ; fhir:Address.line [ fhir:value "32 Fruit Street" ; fhir:index -1 ] ; fhir:Address.city [ fhir:value "Boston" ] ; fhir:Address.state [ fhir:value "MA" ] ; fhir:Address.postalCode [ fhir:value "02114" ] ; fhir:Address.country [ fhir:value "US" ] ] . <http://example.org/fhir/Bundle/PCT-GFE-Bundle-Inst-1> a fhir:Bundle ; fhir:Resource.id [ fhir:value "PCT-GFE-Bundle-Inst-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-bundle> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:Bundle.identifier [ fhir:Identifier.system [ fhir:value "http://example.com/identifiers/bundle" ] ; fhir:Identifier.value [ fhir:value "59688475-2324-3242-23473847" ] ] ; fhir:Bundle.type [ fhir:value "collection"] ; fhir:Bundle.timestamp [ fhir:value "2021-11-09T11:01:00+05:00"^^xsd:dateTime] ; fhir:Bundle.entry [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Claim/PCT-GFE-Summary-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Claim/PCT-GFE-Summary-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Claim/PCT-GFE-Institutional-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Claim/PCT-GFE-Institutional-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/Submitter-Org-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/Submitter-Org-1> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/org1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/org1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Patient/patient1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Patient/patient1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Coverage/coverage1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Coverage/coverage1001> ] . <http://example.org/fhir/Claim/PCT-GFE-Summary-1> a fhir:Claim ; fhir:Resource.id [ fhir:value "PCT-GFE-Summary-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-summary> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:Claim.status [ fhir:value "active"] ; fhir:Claim.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse" ] ; fhir:Coding.code [ fhir:value "estimate-summary" ] ; fhir:Coding.display [ fhir:value "Estimate Summary" ] ] ] ; fhir:Claim.use [ fhir:value "predetermination"] ; fhir:Claim.patient [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] ; fhir:Claim.billablePeriod [ fhir:Period.start [ fhir:value "2021-10-31"^^xsd:date ] ; fhir:Period.end [ fhir:value "2021-10-31"^^xsd:date ] ] ; fhir:Claim.created [ fhir:value "2021-10-05"^^xsd:date] ; fhir:Claim.insurer [ fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ] ; fhir:Claim.provider [ fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "not-applicable" ] ] ] ; fhir:Claim.priority [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/processpriority" ] ; fhir:Coding.code [ fhir:value "normal" ] ] ] ; fhir:Claim.diagnosis [ fhir:index -1 ; fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:Claim.diagnosis.diagnosisCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ] ; fhir:Coding.code [ fhir:value "S06.30" ] ; fhir:Coding.display [ fhir:value "Unspecified focal traumatic brain injury" ] ] ] ; fhir:Claim.diagnosis.type [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/diagnosistype" ] ; fhir:Coding.code [ fhir:value "principal" ] ] ] ; fhir:Claim.diagnosis.packageCode [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup" ] ; fhir:Coding.code [ fhir:value "400" ] ; fhir:Coding.display [ fhir:value "Head trauma - concussion" ] ] ] ] ; fhir:Claim.insurance [ fhir:index -1 ; fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ] ; fhir:Claim.insurance.coverage [ fhir:link <http://hl7.org/fhir/Coverage/coverage1001> ; fhir:Reference.reference [ fhir:value "Coverage/coverage1001" ] ] ] ; fhir:Claim.total [ fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] . <http://example.org/fhir/Claim/PCT-GFE-Institutional-1> a fhir:Claim ; fhir:Resource.id [ fhir:value "PCT-GFE-Institutional-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DomainResource.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology" ] ; fhir:Extension.valueString [ fhir:value "EEMM1021" ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer" ] ; fhir:Extension.valueString [ fhir:value "For estimation purposes only" ] ], [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "linkingIdentifier" ] ; fhir:Extension.valueIdentifier [ fhir:Identifier.system [ fhir:value "http://example.org/Claim/identifiers" ] ; fhir:Identifier.value [ fhir:value "223452-2342-2435-008001" ] ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "plannedPeriodOfService" ] ; fhir:Extension.valueDate [ fhir:value "2021-10-31"^^xsd:date ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo" ] ] ; fhir:Claim.identifier [ fhir:index -1 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "PLAC" ] ] ] ; fhir:Identifier.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Identifier.value [ fhir:value "GFEProviderAssignedID0001" ] ] ; fhir:Claim.status [ fhir:value "active"] ; fhir:Claim.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ] ; fhir:Coding.code [ fhir:value "institutional" ] ; fhir:Coding.display [ fhir:value "Institutional" ] ] ] ; fhir:Claim.use [ fhir:value "predetermination"] ; fhir:Claim.patient [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] ; fhir:Claim.created [ fhir:value "2021-10-05"^^xsd:date] ; fhir:Claim.insurer [ fhir:link <http://hl7.org/fhir/Organization/org1001> ; fhir:Reference.reference [ fhir:value "Organization/org1001" ] ] ; fhir:Claim.provider [ fhir:link <http://hl7.org/fhir/Organization/Submitter-Org-1> ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://nucc.org/provider-taxonomy" ] ; fhir:Coding.code [ fhir:value "2085D0003X" ] ; fhir:Coding.display [ fhir:value "Diagnostic Neuroimaging (Radiology) Physician" ] ] ] ], [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:Reference.reference [ fhir:value "Organization/Submitter-Org-1" ] ] ; fhir:Claim.priority [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/processpriority" ] ; fhir:Coding.code [ fhir:value "normal" ] ] ] ; fhir:Claim.payee [ fhir:Claim.payee.type [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/payeetype" ] ; fhir:Coding.code [ fhir:value "provider" ] ] ] ] ; fhir:Claim.referral [ fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber" ] ; fhir:Extension.valueString [ fhir:value "REF12022002-121" ] ] ; fhir:Reference.display [ fhir:value "Referral Number" ] ] ; fhir:Claim.supportingInfo [ fhir:index -1 ; fhir:Claim.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:Claim.supportingInfo.category [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType" ] ; fhir:Coding.code [ fhir:value "typeofbill" ] ] ] ; fhir:Claim.supportingInfo.code [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "https://www.nubc.org/CodeSystem/TypeOfBill" ] ; fhir:Coding.code [ fhir:value "011X" ] ; fhir:Coding.display [ fhir:value "Hospital Inpatient (Part A)" ] ] ] ] ; fhir:Claim.diagnosis [ fhir:index -1 ; fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:Claim.diagnosis.diagnosisCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ] ; fhir:Coding.code [ fhir:value "S06.30" ] ; fhir:Coding.display [ fhir:value "Unspecified focal traumatic brain injury" ] ] ] ; fhir:Claim.diagnosis.type [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/diagnosistype" ] ; fhir:Coding.code [ fhir:value "principal" ] ] ] ; fhir:Claim.diagnosis.packageCode [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup" ] ; fhir:Coding.code [ fhir:value "400" ] ; fhir:Coding.display [ fhir:value "Head trauma - concussion" ] ] ] ] ; fhir:Claim.insurance [ fhir:index -1 ; fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ] ; fhir:Claim.insurance.coverage [ fhir:link <http://hl7.org/fhir/Coverage/coverage1001> ; fhir:Reference.reference [ fhir:value "Coverage/coverage1001" ] ] ] ; fhir:Claim.item [ fhir:index -1 ; fhir:Element.extension [ fhir:index -1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription" ] ; fhir:Extension.valueString [ fhir:value "Imaging" ] ] ; fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ] ; fhir:Claim.item.revenue [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "https://www.nubc.org/CodeSystem/RevenueCodes" ] ; fhir:Coding.code [ fhir:value "0611" ] ; fhir:Coding.display [ fhir:value "Magnetic Resonance Technology (MRT) - Brain/brain stem" ] ] ] ; fhir:Claim.item.productOrService [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ] ; fhir:Coding.code [ fhir:value "70551" ] ; fhir:Coding.display [ fhir:value "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ] ; fhir:Claim.item.modifier [ fhir:index -1 ; fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://www.ama-assn.org/go/cpt" ] ; fhir:Coding.code [ fhir:value "70551" ] ; fhir:Coding.display [ fhir:value "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material" ] ] ] ; fhir:Claim.item.servicedDate [ fhir:value "2021-10-31"^^xsd:date ] ; fhir:Claim.item.quantity [ fhir:Quantity.value [ fhir:value "1"^^xsd:decimal ] ] ; fhir:Claim.item.net [ fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ] ; fhir:Claim.total [ fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] . <http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1> a fhir:Bundle ; fhir:Resource.id [ fhir:value "PCT-GFE-Missing-Bundle-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-missing-bundle> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:Bundle.identifier [ fhir:Identifier.system [ fhir:value "http://example.com/identifiers/bundle" ] ; fhir:Identifier.value [ fhir:value "59688475-2324-3242-2347384376" ] ] ; fhir:Bundle.type [ fhir:value "collection"] ; fhir:Bundle.timestamp [ fhir:value "2024-03-27T11:01:00+05:00"^^xsd:dateTime] ; fhir:Bundle.entry [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/org1002" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/org1002> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Patient/patient1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Patient/patient1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Coverage/coverage1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Coverage/coverage1001> ], [ fhir:index -1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/org1001" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/Organization/org1001> ], [ fhir:index -1 ; fhir:Element.id [ fhir:value "PCT-DeviceRequest-1" ] ; fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1" ] ; fhir:Bundle.entry.resource <http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1> ] . <http://example.org/fhir/DeviceRequest/PCT-DeviceRequest-1> a fhir:DeviceRequest ; fhir:Resource.id [ fhir:value "PCT-DeviceRequest-1"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest" ; fhir:index -1 ; fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-devicerequest> ] ] ; fhir:Resource.language [ fhir:value "en"] ; fhir:DeviceRequest.status [ fhir:value "active"] ; fhir:DeviceRequest.intent [ fhir:value "proposal"] ; fhir:DeviceRequest.codeCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index -1 ; fhir:Coding.system [ fhir:value "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets" ] ; fhir:Coding.code [ fhir:value "L1820" ] ] ] ; fhir:DeviceRequest.subject [ fhir:link <http://hl7.org/fhir/Patient/patient1001> ; fhir:Reference.reference [ fhir:value "Patient/patient1001" ] ] . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/Bundle/PCT-AEOB-Packet-1.ttl> a owl:Ontology ; owl:imports fhir:fhir.ttl ; owl:versionIRI <http://build.fhir.org/Bundle/PCT-AEOB-Packet-1.ttl> .
IG © 2025+ HL7 International / Financial Management.
Package hl7.fhir.us.davinci-pct#2.0.2 based on FHIR 4.0.1.
Generated
2026-11-09
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