Patient Cost Transparency Implementation Guide
1.0.0 - STU 1 United States of America flag

Patient Cost Transparency Implementation Guide, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Change Log

Change Log

High Level Changes

There were many changes to all the profiles, value sets, etc. since the last ballot. The details are listed in the section below. High level changes since the ballot are:

  • The polling mechanism changed form polling based on Bundle.identifier to using the asyncrhonous response pattern.
  • Updated workflow diagrams on the Use Cases page.
  • Most code systems have been moved to the HL7 terminology page, and their code system URLs changed as a result.
  • Harmonized with CARIN blue button EOB where possible to reduce implementation barriers
  • Added Must Support definition, and updated elements to align with MS definition, and removed MS from elements where the minimum cardinality is 1 since these are required anyway
  • ¬†Updates to the AEOB profile to provide guidance and improve alignment with requirements for patient AEOBs including benefit period, benefit balance, adjudication and supporting info elements

Detailed Changes (JIRA Change Requests)

Key Resolution Summary
FHIR-35228 Persuasive

PCT GFE Institutional .item, remove .item estimated DOS extension

FHIR-34692 Persuasive

Institutional profile - modify mapping of charge amount

FHIR-34816 Persuasive

Professional profile - modify mapping of charge amount

FHIR-34928 Persuasive with Modification

US Core Reference

FHIR-34934 Persuasive with Modification

Terms and concepts - Charge Master Description

FHIR-34935 Persuasive with Modification

Terms and concepts - Collection of Services

FHIR-34938 Persuasive

Systems Update

FHIR-35207 Persuasive with Modification

Disclaimer wording is awkward in MRI scenario

FHIR-35234 Persuasive

Remove section 4.4 Testing requirements

FHIR-34925 Persuasive

In the Coverage profile, remove Must Support from costToBeneficiary

FHIR-34919 Persuasive

Modify AEOB profile to add Practitioner

FHIR-34915 Persuasive with Modification

Require pattern for AEOB profile claim.use; add MS to claim.status

FHIR-34904 Persuasive

AEOB profile - remove expirationDate

FHIR-34661 Persuasive

Remove Must Support from Institutional.facility

FHIR-34505 Persuasive

Clarify wording for Claim Resource in GFE Bundle Resource

FHIR-35236 Persuasive

Remove inherited invariants from profile pages

FHIR-34969 Persuasive with Modification

stronger language in P&S section

FHIR-34936 Persuasive

Terms and concepts - De-identified Minimum Negotiated Rate

FHIR-36025 Persuasive

PCT AEOB Profile - Add PractitionerRole to provider

FHIR-34933 Persuasive

Terms and concepts updates - Consolidated Appropriations Act

FHIR-34976 Persuasive with Modification

change SHOULD to SHALL

FHIR-34931 Persuasive with Modification

Terms and concepts updates - Advanced EOB

FHIR-34939 Persuasive

Downloads

FHIR-35230 Persuasive

PCT GFE Professional - remove procedure:other slice

FHIR-35274 Persuasive

Security and Privacy section mentioning X12

FHIR-34791 Persuasive with Modification

Require pattern for professional profile claim.use; add MS to claim.status

FHIR-35357 Persuasive

Move downloads to its own page with a menu link

FHIR-35344 Persuasive

Add link to GFE Submit operation in referenced Overview text

FHIR-35340 Persuasive

Include link to HRex IG in overview

FHIR-35264 Persuasive

Add link to GFE Submit operation

FHIR-35266 Persuasive

Define AEOB on first use on page

FHIR-34927 Persuasive with Modification

Update Example

FHIR-35200 Persuasive

All diagrams should have an identifier to make it easy to reference.

FHIR-35170 Persuasive with Modification

Add definition of GFE

FHIR-34691 Persuasive with Modification

Institutional profile - remove location extension

FHIR-34995 Persuasive

Clarify a single PCT GFE Bundle SHALL only contain gfe for a single patient

FHIR-34942 Persuasive

GFE Professional Claim .accident, constrain to locationAddress, add binding to country code

FHIR-34941 Persuasive

PCT GFE Institutional - .accident, constrain to locationAddress and add binding for country code

FHIR-35102 Persuasive with Modification

edit definition of Changemaster

FHIR-34650 Persuasive with Modification

Require pattern for institutional profile claim.use; add MS to claim.status

FHIR-34980 Persuasive

Patient Profile - remove employeeID

FHIR-34794 Persuasive with Modification

Define Servicing Facility reference resource as an organization, not a location

FHIR-34984 Persuasive with Modification

Remove PractitionerRole Profile

FHIR-34906 Persuasive with Modification

PCT GFE Institutional supportingInfo:typeOfBill .code

FHIR-34983 Persuasive

Remove the Location Profile

FHIR-35147 Persuasive

Remove Code Systems defined for testing purposes

FHIR-36640 Persuasive

Define Institutional Servicing Facility reference resource as an organization, not a location

FHIR-35256 Persuasive with Modification

More guidance is required for the AEOB Out of network provider info

FHIR-35208 Persuasive

Provide link to the CAA No Surprises legislation

FHIR-35219 Persuasive

PCT GFE Institutional - .careTeam:attending - PCT Practitioner only

FHIR-34953 Persuasive

Payer Intermediary and FHIR-X12 Translators

FHIR-34787 Persuasive

Move Security section to own page as a Menu item

FHIR-34810 Persuasive with Modification

Professional Profile: Difference between the Provider Event Methodology and the Provider GFE Grouper Methodology

FHIR-34809 Persuasive with Modification

Professional Profile - remove location extension

FHIR-37632 Not Persuasive with Modification

Make AEOB .benefitPeriod cardinality 1..1

FHIR-37636 Persuasive

Add markdown datatype to disclaimer extension

FHIR-36200 Persuasive with Modification

AEOB - Add a String Element to contain the Description of the Provided Service

FHIR-37625 Persuasive with Modification

Change AEOB element short description and comments on ExplanationOfBenefit.created

FHIR-34811 Not Persuasive with Modification

Change GFE Billing Provider Line Item Control Number to item.sequence

FHIR-34946 Persuasive with Modification

use of the term "near real time"

FHIR-35097 Persuasive with Modification

Could payers reasonably produce an AEOB in 5 minutes?

FHIR-34892 Persuasive with Modification

Change terminology for 'Submitting Provider' to 'Convening Provider'

FHIR-35233 Persuasive

Fixed display values should not generally be required

FHIR-35145 Not Persuasive with Modification

Practitioner Profile - add NUCC Value Set to .qualification

FHIR-34943 Persuasive with Modification

Remove the Taxonomy extension from Organization

FHIR-35262 Persuasive

Change the use of payor to payer

FHIR-35265 Persuasive

Add EOB.use to explanation of predetermination

FHIR-35268 Persuasive

Correct wording on example regarding occurence of resource

FHIR-36647 Persuasive

Add missing '$' to FSH alias reference.

FHIR-34956 Not Persuasive with Modification

Out of Network Info

FHIR-34792 Persuasive

Modify .provider Reference Resource

FHIR-34900 Persuasive with Modification

PCT Practitioner - Add explicit identifier slice for Tax ID

FHIR-35103 Persuasive

rewrite in third person

FHIR-35263 Persuasive

Update the the finally published version of HRex

FHIR-36198 Persuasive

PCT Coverage - check to ensure is based on HRex - Missing Group Slice in IG

FHIR-37653 Persuasive

Align PCT Coverage with HRex 1.0.0 Coverage

FHIR-35326 Persuasive with Modification

Update Overview to better reflect the workflow

FHIR-34951 Persuasive with Modification

Stronger language as to why Provider SHOULD also receive AEOB

FHIR-34954 Persuasive with Modification

Overview Flow

FHIR-34947 Persuasive with Modification

should state the close relationship between GFEs/AEOBs and X12 claims/ERAs

FHIR-35328 Persuasive

Change overview language regarding X12

FHIR-35322 Persuasive with Modification

Institutional profile - supportingInfo:typeOfBill update

FHIR-35240 Not Persuasive with Modification

Remove Organization.identfier ccn as MS element

FHIR-34944 Not Persuasive with Modification

In the Organization profile, update the ccn identifier description

FHIR-34979 Persuasive with Modification

Organization Profile - add payer id and NAIC identifiers

FHIR-34937 Persuasive

References to CAA

FHIR-34924 Persuasive with Modification

Reference to X12

FHIR-35104 Persuasive with Modification

Advanced EOB Response to Provider(s) Must Be Optional

FHIR-35056 Not Persuasive with Modification

Revise PCT Organization Type Code System

FHIR-34982 Not Persuasive with Modification

Practitioner Profile - update the ccn identifier description

FHIR-34922 Persuasive

In the Coverage profile, define slices for .class

FHIR-35014 Persuasive with Modification

GFE Submitter Must be Uniform Across All GFEs within a Bundle

FHIR-35379 Persuasive

Add invariant requiring only a single GFE submitter

FHIR-34687 Not Persuasive with Modification

Institutional Profile - add estimated admission period

FHIR-34666 Persuasive with Modification

Define DRG as .supportingInfo on Institutional Profile

FHIR-35330 Persuasive

Correct overview wording using IG name

FHIR-35202 Persuasive

"Must Support" is not defined in this IG and it has to be since it is applied to several of the Resources

FHIR-34945 Persuasive with Modification

Organization Profile - delete tin identifier

FHIR-38766 Persuasive

Remove MS from AEOB.item.revenue

FHIR-35237 Persuasive

FHIR US Core 3.1 is required for providers/payers to support adjacent ONC/CMS regulation

FHIR-38125 Persuasive

Remove Must Support from PreAuthRef

FHIR-35294 Not Persuasive with Modification

Coverage Profile - modify .subscriber Reference resource

FHIR-34990 Not Persuasive with Modification

Define RelatedPerson Profile

FHIR-35216 Persuasive with Modification

AEOB Item links to GFE

FHIR-34920 Persuasive

On the AEOB profile, remove requirement for net; add requirement for adjudication

FHIR-37934 Persuasive

Make type of bill on institutional supportinginfo cardinality 1..1

FHIR-35108 Persuasive with Modification

which x12 specifications?

FHIR-36761 Persuasive

Institutional GFE - Chg procedure:primary to procedure:principal, modify definition

FHIR-35243 Not Persuasive with Modification

Add relatedPerson to Subscriber reference types

FHIR-35217 Not Persuasive with Modification

Updating / Cancelling AEOB Request

FHIR-37516 Persuasive with Modification

Change careTeam:rendering slice on Institutional GFE to only be a Human (not Organization)

FHIR-35095 Persuasive

Utilize Distinct FHIR Profiles for Professional and Institutional Claims

FHIR-38126 Persuasive

Add Disclaimer extension to GFEs

FHIR-34948 Persuasive

Make a stronger case as to why FHIR is the best

FHIR-35254 Not Persuasive with Modification

compoundDrugLinkingNum needs more guidance

FHIR-34905 Persuasive with Modification

PCT GFE Professional - Create identifier slices rather than extensions

FHIR-35246 Persuasive with Modification

Create slices on identifier instead of creating extensions

FHIR-35258 Persuasive with Modification

Require type and subtype in AEOB

FHIR-34903 Persuasive with Modification

PCT GFE Institutional - Identifiers. Add slices to .identifier rather than creating extensions

FHIR-35319 Persuasive with Modification

Institutional Profile - define Point of Origin, Admission Type and Discharge Status

FHIR-37720 Persuasive with Modification

Add the extension gfeProviderAssignedIdentifier to the AEOB Profile. (at the header level)

FHIR-34897 Not Persuasive with Modification

PCT Practitioner - remove endpoint extension add slice on contact

FHIR-36193 Not Persuasive with Modification

Plan or Coverage Entity Name and GFE Plan or Coverage Payer Name appear to be the same

FHIR-34901 Persuasive with Modification

Institutional profile - define careTeamSequence

FHIR-34955 Persuasive with Modification

Network status in advanced EOB profile

FHIR-35069 Persuasive with Modification

Professional profile - update careTeam

FHIR-35057 Persuasive with Modification

Institutional profile - add diagnosis slice, add invariants

FHIR-35249 Persuasive with Modification

More clearly define the purpose and constraints of ProviderEventMethodology

FHIR-35273 Persuasive

Provide means to declare an in or out of network/coverage status for AEOB

FHIR-35272 Persuasive with Modification

Provide a means to specify a denial reason in AEOB

FHIR-35222 Persuasive with Modification

PCT GFE Institutional - Claim.CareTeam:operating - PCT Practitioner, fix NUCC

FHIR-35261 Persuasive

Make Conformance statement verbs in bold format

FHIR-38644 Persuasive with Modification

Add provider descriptions for patients to both encounter and claim level

FHIR-37581 Persuasive with Modification

Add clarifying comment to processNote with best practice for patient information

FHIR-38840 Persuasive with Modification

Allow GFE Submitter to be Practitioner in Institutional GFE

FHIR-35088 Persuasive with Modification

Institutional and Professional profiles - NDC mapping and Value Set

FHIR-39416 Persuasive with Modification

Remove disclaimer extension from AEOB and update processNote description and cardinality

FHIR-35453 Persuasive

Harmonize Profiles with the CARIN BB IG

FHIR-34913 Persuasive

Harmonize CARIN BB and PCT FHIR data element mapping and Value Sets

FHIR-35238 Persuasive

Include a CapabilityStatement

FHIR-38842 Persuasive with Modification

Patient should be able to search EOBs, not get Bundles

FHIR-35063 Persuasive with Modification

polling mechanism in question

FHIR-34974 Persuasive with Modification

need to better explain the need for all the workflow steps

FHIR-35271 Persuasive with Modification

AEOB Query should take a different approach

FHIR-34789 Persuasive

Rewrite to make easier to understand the API

FHIR-34997 Persuasive with Modification

Change who gets authentication done in AEOB request from payer

FHIR-34914 Persuasive with Modification

Response to gfe-submit is unclear

FHIR-34952 Persuasive with Modification

Process Flow Revisions

FHIR-34940 Persuasive with Modification

Process for Sharing Advanced EOBs with Providers

FHIR-34533 Persuasive with Modification

Is return type form GFE Submit Appropriate?

FHIR-35124 Persuasive with Modification

Use of the FHIR API for Advanced AOBs to Member Must Be Optional

FHIR-35199 Persuasive with Modification

Diagram in Overview seems to imply that the Patient could only get a response from an Intermediary

FHIR-39463 Persuasive

Remove MS from AEOB.priority

FHIR-39465 Persuasive

Make AEOB.insurance.coverage MS

FHIR-35143 Persuasive with Modification

Professional profile - modify requirement for careTeam.qualification

FHIR-35140 Persuasive with Modification

Institutional profile - modify requirement for careTeam.qualification

FHIR-38771 Persuasive with Modification

Add note in overview that this IG does not address eligibility, prior authorization, or coordination of benefits

FHIR-34964 Persuasive with Modification

provider web portal?

FHIR-38127 Persuasive

GFE profiles need to require item.net

FHIR-35250 Not Persuasive with Modification

Use Claim.billablePeriod instead of creating a new extension

FHIR-34785 Persuasive with Modification

simplify menu navigation

FHIR-37963 Persuasive

Redesign subjectToMedicalMgmt extension to support CodeableConcept and string

FHIR-34786 Persuasive with Modification

Simplify or Replace figures with tables

FHIR-35051 Persuasive with Modification

Modify GFE and AEOB Bundle Graphics

FHIR-39415 Persuasive with Modification

Add service description to AEOB header

FHIR-34532 Persuasive

Need example of return from gfe-submit

FHIR-34963 Persuasive with Modification

GFE and AEOB Bundle Graphics

FHIR-39397 Persuasive

Add clarity for the operation outcome when server doesn't include AEOB

FHIR-34962 Persuasive

GFE and AEOB Bundle Graphics

FHIR-39346 Persuasive

Add a slice on AEOB.identifier for unique claim id to align with CARIN, but clarify in the description that it is the payer's claim id.

FHIR-34961 Persuasive with Modification

Detailed Requirements Summary

FHIR-35269 Persuasive with Modification

Specify OperationOutcome requirements for common outcomes

FHIR-39379 Persuasive with Modification

Make date of service required and add search parameter

FHIR-38770 Persuasive

Add Operational requirement that the GFE linked in the AEOB is an exact copy of the provider submitted GFE Bundle

FHIR-38120 Persuasive

Add an Operational requirement about GFE stored as is as originally received and not updated.

FHIR-38738 Persuasive with Modification

Define assumptions about what payers must verify in the GFE

FHIR-39380 Persuasive

Guiding principle for repeating items in GFE in AEOB

FHIR-38122 Persuasive

Specify more details on the scope of the IG regarding coordination of benefits and other use cases

FHIR-35260 Persuasive with Modification

Add slice requirements for AEOB adjudication categories

FHIR-38835 Persuasive

Consider GFE Value to Indicate if Member Has Agreed to Balance Billing

FHIR-35378 Persuasive with Modification

Add entry slices on Bundles for expected and required resource types

FHIR-34930 Persuasive

Add Relationshiop Diagram