|Standard / Implementation Specification
|Standards Process Maturity
|Test Tool Availability
Yes – Open
|Limitations, Dependencies, and Preconditions for Consideration
Applicable Security Patterns for Consideration
This IG is not required for use at this time. Its development is informed by the No Surprises Act (see Division BB, Title I, Sections 111 and 112), which was enacted as part of the Consolidated Appropriations Act, 2021. The No Surprises Act specifically requires that a provider share GFEs with a payer and that a payer make an AEOB available to a patient in advance of service. The initial scope of this IG was inspired by this general requirement.
This IG provides detailed guidance to support providers and payers exchanging financial information for specific services and items using FHIR-based standards.
The exchange involves a provider submitting a Good Faith Estimate (GFE) to a payer, and the payer generating an Advanced Explanation of Benefits (AEOB) for a patient (which may optionally be returned to the submitting provider). This information about the cost of healthcare items or services could enable better decision making by the patient in consultation with the provider. Note: This exchange will be triggered via a “request” or “scheduled service”. The AEOB will also include the GFE used to inform the AEOB generation.
This specification is a Standard for Trial Use. It is expected to continue to evolve and improve through HL7® FHIR® Connectathon testing and feedback from early adopters.
Criteria regarding what payers must verify in a good faith estimate (GFE) will be evaluated during the next phase of the project after the project stakeholders receive feedback on error handling during testing and implementation.
Feedback is welcome and may be submitted through the FHIR change tracker indicating "US Da Vinci PCT" as the specification.
This implementation guide (IG) is dependent on other specifications. Please submit any comments you have on these base specifications as follows:
The sharing of information from provider to payer for determining an Advanced Explanation of Benefits (AEOB) is subject to the Health Insurance Portability and Accountability Act’s (HIPAA) “minimum necessary” regulations (specifically 45 CFR 164.514(d)(3) and (d)(4)). Payers are responsible for ensuring that only information necessary to create an AEOB is solicited, and providers are responsible for ensuring that only data that is reasonably relevant to creating an AEOB is transmitted.