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
Language: en
Profile: PCT GFE Bundle
Bundle PCT-GFE-Bundle-Prof-1 of type collection
Entry 1 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Summary-MRI
Resource Claim:
Language: en
Profile: PCT Good Faith Estimate Summary
status: Active
type: Estimate Summary
use: Predetermination
billablePeriod: 2021-10-31 --> (ongoing)
created: 2021-10-05
insurer: Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)
provider: ?rref?
priority: Normal
Diagnoses
Sequence Type 1 Principal Diagnosis Insurances
Sequence Focal Coverage 1 true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01 Totals
Value Currency 200 USD
Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI
Resource Claim:
Language: en
Profile: PCT Good Faith Estimate Professional
ProviderEventMethodology: EEMM1022
GFEServiceLinkingInfo
- linkingIdentifier:
http://example.org/Claim/identifiers/223452-2342-2435-008001- plannedPeriodOfService: 2021-10-31
identifier: Placer Identifier/GFEProviderAssignedID0002
status: Active
type: Professional
use: Predetermination
created: 2021-10-05
insurer: Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)
provider: Nora Ologist (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#9941339100)
priority: Normal
Payees
Type Provider referral: Referral Number
Diagnoses
Sequence Type 1 Principal Diagnosis Insurances
Sequence Focal Coverage 1 true Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01 item
Service Description: Imaging
GFEBillingProviderLineItemCtrlNum: GFEBillingProviderLineItemCtrlNum-0001
sequence: 1
productOrService: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
modifier: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
serviced: 2021-10-31
location: Inpatient Hospital
quantity: 1
UnitPrices
Value Currency 200 USD Nets
Value Currency 200 USD Totals
Value Currency 200 USD
Entry 3 - fullUrl = http://example.org/fhir/Practitioner/Submitter-Practitioner-1
Resource Practitioner:
Language: en
Profile: PCT Practitioner
Nora Ologist (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#9941339100)
Active: true Other Id: Electronic Transmitter Identification Number/ETIN-20020001 Contact Detail
- ph: 860-547-3301(Work)
- csender@GFEServiceHelp.com
Entry 4 - fullUrl = http://example.org/fhir/Organization/org1001
Resource Organization:
Language: en
Profile: PCT Organization
Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)
Active: true Type: Payer Contact Detail
- ph: 860-547-5001(Work)
- 680 Asylum Street Hartford CT 06155 US
Entry 5 - fullUrl = http://example.org/fhir/Patient/patient1001
Resource Patient:
Eve Betterhalf female, DoB: 1955-07-23 (
http://example.com/identifiers/patient/1001)
Marital Status: unmarried Contact Details:
- ph: 781-949-4949(MOBILE)
- 222 Burlington Road, Bedford MA 01730
Language: English (United States) (preferred)
Entry 6 - fullUrl = http://example.org/fhir/Coverage/coverage1001
Resource Coverage:
Language: en
Profile: PCT Coverage
R5: insurance | self-pay | other (new): insurance
status: Active
subscriberId: PFP123450000
beneficiary: Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)
relationship: Self
period: 2021-01-01 --> 2022-01-01
Classes
Type Value Name Plan Premim Family Plus Premim Family Plus Plan CostToBeneficiaries
Type Value[x] Copay Percentage 20
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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