PCTGFEProfessional

PCT Good Faith Estimate Professional

activeDa Vinci PCT2.0.1resource58 key elements

PCT Good Faith Estimate Professional is a profile for an professional 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 to be processed by a payer for the creation of an Advanced EOB. This profile is used for a professional GFE submission.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional
ID
davinci-pct-gfe-professional
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+
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+
:rendering0..*
S
careTeam.qualification
1+
Practitioner credential or specialization - must provide a taxonomy code for the Professional case
:referring0..1
S
supportingInfo
S
:serviceFacility0..1
S
Service Facility
supportingInfo.value[x]
1+
:valueReference1..1
Reference
1+
:claimFrequency0..1
S
Claim Frequency component of the UB-04 Type of Bill Code (4th digit of the UB-04 Type of Bill code).
supportingInfo.code
1+
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+
:other0..11
S
diagnosis.type1..1
1+
procedure
S
procedure.extension
1+
:serviceDescription1..1
Extension
1+
procedure.type
S
:anesthesiaRelated0..2
S
: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..50
1+
item.extension
1+
:referralNumber0..11
Extension
S
Referral Number
:gfeBillingProviderLineItemCtrlNum0..1
Extension
S
:serviceDescription1..1
Extension
1+
:ProviderEventMethodology0..1
Extension
S
Provider Event Methodology
item.careTeamSequence
S
item.modifier
S
item.serviced[x]
S1+
This is the planned or estimated date(s)s of service
item.location[x]
CodeableConcept
1+
item.quantity
1+
item.unitPrice
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