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

: PCT-GFE-Professional-MRI

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@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/Claim/PCT-GFE-Professional-MRI> a fhir:Claim ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "PCT-GFE-Professional-MRI"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional>
     ]
  ] ;
  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\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PCT-GFE-Professional-MRI</b></p><a name=\"PCT-GFE-Professional-MRI\"> </a><a name=\"hcPCT-GFE-Professional-MRI\"> </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-gfe-professional.html\">PCT Good Faith Estimate Professional</a></p></div><p><b>ProviderEventMethodology</b>: EEMM1022</p><blockquote><p><b>GFEServiceLinkingInfo</b></p><ul><li>linkingIdentifier: <code>http://example.org/Claim/identifiers</code>/223452-2342-2435-008001</li><li>plannedPeriodOfService: 2021-10-31</li></ul></blockquote><p><b>identifier</b>: Placer Identifier/GFEProviderAssignedID0002</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}\">Professional</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href=\"Patient-patient1001.html\">Eve Betterhalf Female, DoB: 1955-07-23 ( http://example.com/identifiers/patient#1001)</a></p><p><b>created</b>: 2021-10-05</p><p><b>insurer</b>: <a href=\"Organization-org1001.html\">Umbrella Insurance Company (Payer) (Electronic Transmitter Identification Number: ETIN-3200002)</a></p><p><b>provider</b>: <a href=\"Practitioner-Submitter-Practitioner-1.html\">Nora Ologist (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><h3>Payees</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></td></tr></table><p><b>referral</b>: Referral Number</p><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td><td><b>PackageCode</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm S06.30}\">Unspecified focal traumatic brain injury</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/diagnosistype principal}\">Principal Diagnosis</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup 400}\">Head trauma - concussion</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Coverage-coverage1001.html\">Coverage: extension = insurance; status = active; subscriberId = PFP123450000; relationship = Self; period = 2021-01-01 --&gt; 2022-01-01</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Description</b>: Imaging</p><p><b>GFEBillingProviderLineItemCtrlNum</b>: GFEBillingProviderLineItemCtrlNum-0001</p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 70551}\">Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material</span></p><p><b>modifier</b>: <span title=\"Codes:{http://www.ama-assn.org/go/cpt 70551}\">Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material</span></p><p><b>serviced</b>: 2021-10-31</p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}\">Inpatient Hospital</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</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>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>200</td><td>United States dollar</td></tr></table></blockquote><h3>Totals</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>200</td><td>United States dollar</td></tr></table></div>"
  ] ;
  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 "EEMM1022" ]
  ], [
     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 "GFEProviderAssignedID0002" ]
  ] ;
  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 "professional" ] ;
       fhir:Coding.display [ fhir:value "Professional" ]
     ]
  ] ;
  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/Practitioner/Submitter-Practitioner-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:Reference.reference [ fhir:value "Practitioner/Submitter-Practitioner-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 "REF12022002-122" ]
     ] ;
     fhir:Reference.display [ fhir:value "Referral Number" ]
  ] ;
  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:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum" ] ;
       fhir:Extension.valueIdentifier [
         fhir:Identifier.value [ fhir:value "GFEBillingProviderLineItemCtrlNum-0001" ]
       ]
     ] ;
     fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     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.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ] ;
         fhir:Coding.code [ fhir:value "21" ] ;
         fhir:Coding.display [ fhir:value "Inpatient Hospital" ]
       ]
     ] ;
     fhir:Claim.item.quantity [
       fhir:Quantity.value [ fhir:value "1"^^xsd:decimal ]
     ] ;
     fhir:Claim.item.unitPrice [
       fhir:Money.value [ fhir:value "200"^^xsd:decimal ] ;
       fhir:Money.currency [ fhir:value "USD" ]
     ] ;
     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://hl7.org/fhir/Patient/patient1001> a fhir:Patient .

<http://hl7.org/fhir/Organization/org1001> a fhir:Organization .

<http://hl7.org/fhir/Practitioner/Submitter-Practitioner-1> a fhir:Practitioner .

<http://hl7.org/fhir/Coverage/coverage1001> a fhir:Coverage .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/Claim/PCT-GFE-Professional-MRI.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/Claim/PCT-GFE-Professional-MRI.ttl> .