PCTGFEInstitutional

PCT Good Faith Estimate Institutional

activeDa Vinci PCT2.0.1resource69 key elements

PCT Good Faith Estimate Institutional is a profile for an institutional provider to capture estimation for items and services for the patient or, optionally, to submit to a payer (for patients using insurance). If submitting to a payer, this includes the data needed for a payer to process and create an Advanced EOB. This profile is used for an institutional GFE submission.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional
ID
davinci-pct-gfe-institutional
Type
Base Definition
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
:gfeServiceLinkingInfo0..1
Extension
S
GFE Service Linking Information.
:providerEventMethodology0..1
Extension
S
Provider event collection methodology
:gfeDisclaimer0..*
Extension
S
Disclaimers the patient should be made aware of regarding the providers estimate, e.g. application of sliding scale for self-pay/uninsured patients
identifier
1+
:PLAC1..1
1+
Provider Assigned Identifier for GFE Claim
identifier.type
1+
identifier.system
S
identifier.value
1+
billablePeriod
S
Relevant time frame for the claim. This is per claim, whereas a planned period of service can span multiple claims.
provider.extension
1+
:providerTaxonomy1..1
Extension
1+
Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers
:consentForBalanceBilling0..1
Extension
S
payee
S
referral.extension
1+
:referralNumber1..1
Extension
1+
Referral Number
careTeam
S
careTeam.role
1+
:attending0..1
S
careTeam.qualification
1+
:operating0..2
S
:rendering0..1
S
:referring0..1
S
supportingInfo
S1+
:typeOfBill1..1
S1+
supportingInfo.code
1+
:serviceFacility0..1
S
Service Facility
supportingInfo.value[x]
1+
:valueReference1..1
Reference
1+
:drg0..1
S
:pointoforigin0..1
S
:admtype0..1
S
diagnosis
S
diagnosis.type
S
:principal0..1
S
Principal Diagnosis - Must Support means the information source SHALL be capable of populating and SHALL populate if available and permitted.
diagnosis.type1..1
1+
:admitting0..1
S
diagnosis.type1..1
1+
:patientReasonForVisit0..3
S
diagnosis.type1..1
1+
:externalcauseofinjury0..12
S
diagnosis.type1..1
1+
:other0..24
S
diagnosis.diagnosis[x]
CodeableConcept
S
diagnosis.type1..1
1+
procedure
S
procedure.extension
1+
:serviceDescription1..1
Extension
1+
procedure.type
S
:principal0..1
S
Principal clinical procedure performed
:serviceDescription1..1
Extension
1+
procedure.type1..1
1+
:other0..24
S
:serviceDescription1..1
Extension
1+
procedure.type1..1
1+
:dataAbsentReason0..1
Extension
S
Coverage may be not applicable if estimate is for self-pay or uninsured
item1..999
1+
item.extension
1+
:gfeBillingProviderLineItemCtrlNum0..1
Extension
S
:serviceDescription1..1
Extension
1+
:ProviderEventMethodology0..1
Extension
S
Provider Event Methodology
item.revenue
1+
Revenue or cost center code - must provide a value for the Institutional case
item.modifier
S
item.serviced[x]
S1+
This is the planned or estimated date(s)s of service
:locationCodeableConcept0..1
CodeableConcept
S
item.quantity
1+
item.net
1+
Total charge amount for the service line
item.detail
S
Drug Identification Information
item.detail.quantity
S
total
1+
Total GFE Charges Submitted