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Patient Cost Transparency Implementation Guide Payer Capability Statement

Title:Patient Cost Transparency Implementation Guide Payer Capability Statement

Implementation Guide Version: 2.0.0-draft

FHIR Version: 4.0.1

Intended Use: Requirements

Supported Formats: SHALL support json; SHOULD support xml;

Published: 2023-03-28 14:21:32-0500

Published by: HL7 International / Financial Management

Status: Active

Copyright:

Used by permission of HL7 International, all rights reserved Creative Commons License

Description:

Payer capability statement for the Da Vinci Patient Cost Transparency Implementation Guide

Support and Requirements for Other Artifacts

Imports other capabilities:

US Core Server CapabilityStatement

Jump to:

REST Server

FHIR Server RESTful Capabilities

System-wide Server Capabilities

Summary of Resource/Profile Capabilities

♦ = SHALL expectation; ⋄ = SHOULD expectation; ▿ = MAY expectation;

Resource Type | Supported Interactions | Supported Profiles | Supported Searches | Supported _includes | Supported _revincludes | Supported Operations
Bundle | create▿, search-type♦, read♦, vread▿, update▿, patch▿, delete▿, history-instance▿, history-type▿, | PCT AEOB Packet, PCT GFE Bundle, PCT GFE Packet, | estimate-initiation-time♦, estimate-service♦, estimate-condition♦, linking-identifier♦, planned-period♦, | | | $GFESubmit♦
ExplanationOfBenefit | create▿, search-type♦, read♦, vread▿, update▿, patch▿, delete▿, history-instance▿, history-type▿, | PCT Advanced EOB♦, | | | |
Coverage | create▿, search-type♦, read♦, vread▿, update▿, patch▿, delete▿, history-instance▿, history-type▿, | PCT Coverage♦, | | | |
Claim | create▿, search-type♦, read♦, vread▿, update▿, patch▿, delete▿, history-instance▿, history-type▿, | PCT Good Faith Estimate Professional, PCT Good Faith Estimate Institutional, | | | |
Organization | create▿, search-type♦, read♦, vread▿, update▿, patch▿, delete▿, history-instance▿, history-type▿, | PCT Organization♦, | | | |
Practitioner | create▿, search-type♦, read♦, vread▿, update▿, patch▿, delete▿, history-instance▿, history-type▿, | PCT Practitioner♦, | | | |

RESTful Server Capabilities by Resource/Profile:

Bundle

Conformance Expectation:

Supported Profiles:

SHALL support PCT AEOB Packet

SHOULD support PCT GFE Bundle

SHOULD support PCT GFE Packet

Bundle Interaction Summary:

SHALL support search-type, read,

MAY support create, vread, update, patch, delete, history-instance, history-type,

Modify Criteria:

A Server MAY be capable of a create interaction creating a Bundle resource using: POST [base]/Bundle/[id]{?_format=[mime-type]}

A Server MAY be capable of updating a existing Bundle resource using: PUT [base]/Bundle/[id]{?_format=[mime-type]}

A Server MAY be capable of patching an existing Bundle resource using: PATCH [base]/Bundle/[id]{?_format=[mime-type]}

A Server MAY be capable of deleting a Bundle resource using: DELETE [base]//[id]

Fetch and Search Criteria:

A Server SHALL be capable of a search-type interaction returning Bundle resources matching a search query using: GET [base]/Bundle/[id]{?[parameters]{&_format=[mime-type]}}

A Server SHALL be capable of a read interaction returning a Bundle resource using: GET [base]/Bundle/[id]

A Server MAY be capable of a vread interaction returning a Bundle resource using: GET [base]/Bundle/[id]/_history/vid

A Server MAY be capable of a history-instance interaction returning a history of a Bundle using: GET [base]/Bundle/[id]/_history{?[parameters]&_format=[mime-type]}

A Server MAY be capable of a history-type interaction returning the history of Bundle resources using: GET [base]/Bundle/_history{?[parameters]&_format=[mime-type]}

Search Parameter Summary:

Conformance | Parameter | Type | Example
SHALL | estimate-initiation-time | Date/DateTime | GET [base]/Bundle?estimate-initiation-time=[dateTime]
SHALL | estimate-service | Token | GET [base]/Bundle?estimate-service=[system]|[code]
SHALL | estimate-condition | Token | GET [base]/Bundle?estimate-condition=[system]|[code]
SHALL | linking-identifier | Token | GET [base]/Bundle?linking-identifier=[system]|[code]
SHALL | planned-period | Date/DateTime | GET [base]/Bundle?planned-period=[dateTime]

Search Parameter Requirements (When Used Alone or in Combination):

estimate-initiation-time (Date/DateTime):

Instant from which the request originating request was being initiated.

estimate-service (Token):

Significant Procedures and/or products involved in an estimate in the packet.

estimate-condition (Token):

Significant condition involved in an estimate in the packet.

linking-identifier (Token):

An identifier assigned to a particular service or series of services to enabling linking.

planned-period (Date/DateTime):

Planned date(s) of a particular admission/service or a series of admissions/services.

ExplanationOfBenefit

Conformance Expectation:

Supported Profiles:

SHALL support PCT Advanced EOB

Modify Criteria:

A Server MAY be capable of a create interaction creating a ExplanationOfBenefit resource using: POST [base]/ExplanationOfBenefit/[id]{?_format=[mime-type]}

A Server MAY be capable of updating a existing ExplanationOfBenefit resource using: PUT [base]/ExplanationOfBenefit/[id]{?_format=[mime-type]}

A Server MAY be capable of patching an existing ExplanationOfBenefit resource using: PATCH [base]/ExplanationOfBenefit/[id]{?_format=[mime-type]}

A Server MAY be capable of deleting a ExplanationOfBenefit resource using: DELETE [base]//[id]

Fetch and Search Criteria:

A Server SHALL be capable of a search-type interaction returning ExplanationOfBenefit resources matching a search query using: GET [base]/ExplanationOfBenefit/[id]{?[parameters]{&_format=[mime-type]}}

A Server SHALL be capable of a read interaction returning a ExplanationOfBenefit resource using: GET [base]/ExplanationOfBenefit/[id]

A Server MAY be capable of a vread interaction returning a ExplanationOfBenefit resource using: GET [base]/ExplanationOfBenefit/[id]/_history/vid

A Server MAY be capable of a history-instance interaction returning a history of a ExplanationOfBenefit using: GET [base]/ExplanationOfBenefit/[id]/_history{?[parameters]&_format=[mime-type]}

A Server MAY be capable of a history-type interaction returning the history of ExplanationOfBenefit resources using: GET [base]/ExplanationOfBenefit/_history{?[parameters]&_format=[mime-type]}

Coverage

Conformance Expectation:

Supported Profiles:

SHALL support PCT Coverage

Modify Criteria:

A Server MAY be capable of a create interaction creating a Coverage resource using: POST [base]/Coverage/[id]{?_format=[mime-type]}

A Server MAY be capable of updating a existing Coverage resource using: PUT [base]/Coverage/[id]{?_format=[mime-type]}

A Server MAY be capable of patching an existing Coverage resource using: PATCH [base]/Coverage/[id]{?_format=[mime-type]}

A Server MAY be capable of deleting a Coverage resource using: DELETE [base]//[id]

Fetch and Search Criteria:

A Server SHALL be capable of a search-type interaction returning Coverage resources matching a search query using: GET [base]/Coverage/[id]{?[parameters]{&_format=[mime-type]}}

A Server SHALL be capable of a read interaction returning a Coverage resource using: GET [base]/Coverage/[id]

A Server MAY be capable of a vread interaction returning a Coverage resource using: GET [base]/Coverage/[id]/_history/vid

A Server MAY be capable of a history-instance interaction returning a history of a Coverage using: GET [base]/Coverage/[id]/_history{?[parameters]&_format=[mime-type]}

A Server MAY be capable of a history-type interaction returning the history of Coverage resources using: GET [base]/Coverage/_history{?[parameters]&_format=[mime-type]}

Claim

Conformance Expectation:

Supported Profiles:

SHALL support PCT Good Faith Estimate Professional

SHALL support PCT Good Faith Estimate Institutional

Modify Criteria:

A Server MAY be capable of a create interaction creating a Claim resource using: POST [base]/Claim/[id]{?_format=[mime-type]}

A Server MAY be capable of updating a existing Claim resource using: PUT [base]/Claim/[id]{?_format=[mime-type]}

A Server MAY be capable of patching an existing Claim resource using: PATCH [base]/Claim/[id]{?_format=[mime-type]}

A Server MAY be capable of deleting a Claim resource using: DELETE [base]//[id]

Fetch and Search Criteria:

A Server SHALL be capable of a search-type interaction returning Claim resources matching a search query using: GET [base]/Claim/[id]{?[parameters]{&_format=[mime-type]}}

A Server SHALL be capable of a read interaction returning a Claim resource using: GET [base]/Claim/[id]

A Server MAY be capable of a vread interaction returning a Claim resource using: GET [base]/Claim/[id]/_history/vid

A Server MAY be capable of a history-instance interaction returning a history of a Claim using: GET [base]/Claim/[id]/_history{?[parameters]&_format=[mime-type]}

A Server MAY be capable of a history-type interaction returning the history of Claim resources using: GET [base]/Claim/_history{?[parameters]&_format=[mime-type]}

Organization

Conformance Expectation:

Supported Profiles:

SHALL support PCT Organization

Modify Criteria:

A Server MAY be capable of a create interaction creating a Organization resource using: POST [base]/Organization/[id]{?_format=[mime-type]}

A Server MAY be capable of updating a existing Organization resource using: PUT [base]/Organization/[id]{?_format=[mime-type]}

A Server MAY be capable of patching an existing Organization resource using: PATCH [base]/Organization/[id]{?_format=[mime-type]}

A Server MAY be capable of deleting a Organization resource using: DELETE [base]//[id]

Fetch and Search Criteria:

A Server SHALL be capable of a search-type interaction returning Organization resources matching a search query using: GET [base]/Organization/[id]{?[parameters]{&_format=[mime-type]}}

A Server SHALL be capable of a read interaction returning a Organization resource using: GET [base]/Organization/[id]

A Server MAY be capable of a vread interaction returning a Organization resource using: GET [base]/Organization/[id]/_history/vid

A Server MAY be capable of a history-instance interaction returning a history of a Organization using: GET [base]/Organization/[id]/_history{?[parameters]&_format=[mime-type]}

A Server MAY be capable of a history-type interaction returning the history of Organization resources using: GET [base]/Organization/_history{?[parameters]&_format=[mime-type]}

Practitioner

Conformance Expectation:

Supported Profiles:

SHALL support PCT Practitioner

Modify Criteria:

A Server MAY be capable of a create interaction creating a Practitioner resource using: POST [base]/Practitioner/[id]{?_format=[mime-type]}

A Server MAY be capable of updating a existing Practitioner resource using: PUT [base]/Practitioner/[id]{?_format=[mime-type]}

A Server MAY be capable of patching an existing Practitioner resource using: PATCH [base]/Practitioner/[id]{?_format=[mime-type]}

A Server MAY be capable of deleting a Practitioner resource using: DELETE [base]//[id]

Fetch and Search Criteria:

A Server SHALL be capable of a search-type interaction returning Practitioner resources matching a search query using: GET [base]/Practitioner/[id]{?[parameters]{&_format=[mime-type]}}

A Server SHALL be capable of a read interaction returning a Practitioner resource using: GET [base]/Practitioner/[id]

A Server MAY be capable of a vread interaction returning a Practitioner resource using: GET [base]/Practitioner/[id]/_history/vid

A Server MAY be capable of a history-instance interaction returning a history of a Practitioner using: GET [base]/Practitioner/[id]/_history{?[parameters]&_format=[mime-type]}

A Server MAY be capable of a history-type interaction returning the history of Practitioner resources using: GET [base]/Practitioner/_history{?[parameters]&_format=[mime-type]}

# title
Patient Cost Transparency Implementation Guide Payer Capability Statement

# publisher
HL7 International / Financial Management

# contact[].name
HL7 International / Financial Management

# description
Payer capability statement for the Da Vinci Patient Cost Transparency Implementation Guide

# copyright
Used by permission of HL7 International, all rights reserved Creative Commons License

# rest[].resource[].searchParam[].documentation
Instant from which the request originating request was being initiated.

# rest[].resource[].searchParam[].documentation
Significant Procedures and/or products involved in an estimate in the packet.

# rest[].resource[].searchParam[].documentation
Significant condition involved in an estimate in the packet.

# rest[].resource[].searchParam[].documentation
An identifier assigned to a particular service or series of services to enabling linking.

# rest[].resource[].searchParam[].documentation
Planned date(s) of a particular admission/service or a series of admissions/services.

# rest[].resource[].operation[].documentation
This operation is used by an entity to submit one or multiple GFEs as a Bundle containing the GFE(s) and other referenced resources for processing. The only input parameter is the single Bundle resource with one or multiple GFE(s) - each of which is based on the Claim resource (along with other referenced resources). The only output is a url for subsequent polling per [async pattern](https://hl7.org/fhir/R5/async-bundle.html). If after polling the response is complete, then the result will either be a single Bundle with the AEOB - which is based on the ExplanationOfBenefit resource, (and other referenced resources) or an OperationOutcome resource indicating the AEOB will be sent directly to the patient.