HL7.FHIR.US.CARIN-BB\C4BB Adjudication Category Discriminator

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot

This page is part of the CARIN Blue Button Implementation Guide (v1.2.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

ValueSet: C4BB Adjudication Category Discriminator

Summary

Defining URL:

http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator

Version:

1.2.0

Name:

C4BBAdjudicationCategoryDiscriminator

Title:

C4BB Adjudication Category Discriminator

Status:

Active as of 12/6/21 8:26 PM

Definition:

Used as the discriminator for adjudication.category and item.adjudication.category for the CARIN IG for Blue Button®

Publisher:

HL7 Financial Management Working Group

Copyright:

This Valueset is not copyrighted.

Source Resource:

XML / JSON / Turtle

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

Import all the codes that are contained in http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
Import all the codes that are contained in http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
Include all codes defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator

Expansion

This value set contains 21 concepts

Expansion based on:

Code	System	Display	Definition
submitted	http://terminology.hl7.org/CodeSystem/adjudication	Submitted Amount	The total submitted amount for the claim or group or line item.
copay	http://terminology.hl7.org/CodeSystem/adjudication	CoPay	Patient Co-Payment
eligible	http://terminology.hl7.org/CodeSystem/adjudication	Eligible Amount	Amount of the change which is considered for adjudication.
deductible	http://terminology.hl7.org/CodeSystem/adjudication	Deductible	Amount deducted from the eligible amount prior to adjudication.
benefit	http://terminology.hl7.org/CodeSystem/adjudication	Benefit Amount	Amount payable under the coverage
coinsurance	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Coinsurance	The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.
noncovered	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Noncovered	The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
priorpayerpaid	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Prior payer paid	The reduction in the payment amount to reflect the carrier as a secondary payer.
paidbypatient	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Paid by patient	The amount paid by the patient.
paidbypatientcash	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Paid by patient - cash	The amount paid by the patient using cash, check, or other personal account.
paidbypatientother	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Paid by patient - other	The amount paid by the patient using another method like HSA, HRA, or another means other than by cash, check, or other personal account.
paidtopatient	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Paid to patient	paid to patient
paidtoprovider	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Paid to provider	The amount paid to the provider.
memberliability	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Member liability	The amount of the member's liability.
discount	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Discount	The amount of the discount
drugcost	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication	Drug cost	Price paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration
innetwork	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus	In Network	Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
outofnetwork	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus	Out Of Network	Indicates the claim or claim line was paid out of network. This does not indicate the contracting status of the provider
other	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus	Other	Indicates other network status or when a network does not apply
allowedunits	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator	allowed units	defines the adjudication slice to define allowed units
denialreason	http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator	Denial Reason	defines the adjudication slice to identify the denial reason

Explanation of the columns that may appear on this page:

Level

A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies

Source

The source of the definition of the code (when the value set draws in codes defined elsewhere)

Code

The code (used as the code in the resource instance)

Display

The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application

Definition

An explanation of the meaning of the concept

Comments

Additional notes about how to use the code