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
| Page standards status: Informative |
@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/ExplanationOfBenefit/PCT-AEOB-1> a fhir:ExplanationOfBenefit ;
fhir:nodeRole fhir:treeRoot ;
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\"><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/Bundle/PCT-GFE-Bundle-Inst-1> a fhir:Bundle .
<http://hl7.org/fhir/Patient/patient1001> a fhir:Patient .
<http://hl7.org/fhir/Organization/org1001> a fhir:Organization .
<http://hl7.org/fhir/Organization/org1002> a fhir:Organization .
<http://hl7.org/fhir/Coverage/coverage1001> a fhir:Coverage .
# - ontology header ------------------------------------------------------------
<http://hl7.org/fhir/ExplanationOfBenefit/PCT-AEOB-1.ttl> a owl:Ontology ;
owl:imports fhir:fhir.ttl ;
owl:versionIRI <http://build.fhir.org/ExplanationOfBenefit/PCT-AEOB-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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