Patient Cost Transparency Implementation Guide
2.0.2 - STU 2 United States of America flag

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

Example Bundle: PCT-GFE-Packet-Prof-1

Document Subject

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)

Document Content

Coverage Section

Generated Narrative: Coverage coverage1001

Extension Definition for Coverage.kind for Version 5.0: 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

payor: Organization Umbrella Insurance Company

Classes

-TypeValueName
*PlanPremim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage20

GFE Section

Generated Narrative: Claim PCT-GFE-Summary-MRI

status: Active

type: Estimate Summary

use: Predetermination

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

billablePeriod: 2021-10-31 --> (ongoing)

created: 2021-10-05

insurer: Organization Umbrella Insurance Company

provider: ?rref?

priority: Normal

Diagnoses

-SequenceDiagnosis[x]TypePackageCode
*1Unspecified focal traumatic brain injuryPrincipal DiagnosisHead trauma - concussion

Insurances

-SequenceFocalCoverage
*1trueCoverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

Totals

-ValueCurrency
*200United States dollar

GFE Section

Generated Narrative: PCT-GFE-Missing-Bundle-1

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

coverage: Coverage_coverage1001, period: 2021-01-01 --> 2022-01-01

organization: Umbrella Insurance Company

Requested Services

  • device request: KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

Additional Resources Included in Document

Entry 2 - 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 3 - 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

-TypeValueName
*PlanPremim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage20

Entry 4 - 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

Entry 5 - 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 6 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Bundle-Prof-1

Resource Bundle:

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

-SequenceType
*1Principal Diagnosis

Insurances

-SequenceFocalCoverage
*1trueCoverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --> 2022-01-01

Totals

-ValueCurrency
*200USD

Entry 2 - fullUrl = http://example.org/fhir/Claim/PCT-GFE-Professional-MRI

Resource Claim:

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

-SequenceType
*1Principal Diagnosis

Insurances

-SequenceFocalCoverage
*1trueCoverage: 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

-ValueCurrency
*200USD

Nets

-ValueCurrency
*200USD

Totals

-ValueCurrency
*200USD

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

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

-TypeValueName
*PlanPremim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage20

Entry 7 - fullUrl = http://example.org/fhir/Bundle/PCT-GFE-Missing-Bundle-1

Resource Bundle:

Language: en

Profile: PCT GFE Missing Bundle

Bundle PCT-GFE-Missing-Bundle-1 of type collection

Entry 1 - fullUrl = http://example.org/fhir/Organization/org1002

Resource Organization:

Language: en

Profile: PCT Organization

Boston Radiology Center (Healthcare Provider) (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#9941339100)

Active:true
Type:Healthcare Provider
Other Id:Tax ID number/TAX-3211001
Contact Detail
  • ph: 781-232-3200(Work)
  • 32 Fruit Street Boston MA 02114 US

Entry 2 - 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 3 - 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

-TypeValueName
*PlanPremim Family PlusPremim Family Plus Plan

CostToBeneficiaries

-TypeValue[x]
*Copay Percentage20

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/DeviceRequest/PCT-DeviceRequest-1

Resource DeviceRequest:

Language: en

Profile: PCT GFE DeviceRequest

status: Active

intent: Proposal

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