CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.1.0 - STU1 Update

This page is part of the CARIN Blue Button Implementation Guide (v1.1.0: STU 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

: C4BB Adjudication - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:ValueSet;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "C4BBAdjudication"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This value set includes codes based on the following rules:</p><ul><li>Include these codes as defined in <a href=\"https://terminology.hl7.org/1.0.0//CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"https://terminology.hl7.org/1.0.0//CodeSystem-adjudication.html#adjudication-submitted\">submitted</a></td><td>Submitted Amount</td><td>The total submitted amount for the claim or group or line item.</td></tr><tr><td><a href=\"https://terminology.hl7.org/1.0.0//CodeSystem-adjudication.html#adjudication-copay\">copay</a></td><td>CoPay</td><td>Patient Co-Payment</td></tr><tr><td><a href=\"https://terminology.hl7.org/1.0.0//CodeSystem-adjudication.html#adjudication-eligible\">eligible</a></td><td>Eligible Amount</td><td>Amount of the change which is considered for adjudication.</td></tr><tr><td><a href=\"https://terminology.hl7.org/1.0.0//CodeSystem-adjudication.html#adjudication-deductible\">deductible</a></td><td>Deductible</td><td>Amount deducted from the eligible amount prior to adjudication.</td></tr><tr><td><a href=\"https://terminology.hl7.org/1.0.0//CodeSystem-adjudication.html#adjudication-benefit\">benefit</a></td><td>Benefit Amount</td><td>Amount payable under the coverage</td></tr></table></li><li>Include these codes as defined in <a href=\"CodeSystem-C4BBAdjudication.html\"><code>http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-coinsurance\">coinsurance</a></td><td>Coinsurance</td><td>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%.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-noncovered\">noncovered</a></td><td>Noncovered</td><td>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.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-priorpayerpaid\">priorpayerpaid</a></td><td>Prior payer paid</td><td>The reduction in the payment amount to reflect the carrier as a secondary payor.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatient\">paidbypatient</a></td><td>Paid by patient</td><td>The amount paid by the patient at the point of service.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtopatient\">paidtopatient</a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtoprovider\">paidtoprovider</a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-memberliability\">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-drugcost\">drugcost</a></td><td>Drug cost</td><td>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</td></tr></table></li></ul></div>"
  ];
  fhir:ValueSet.url [ fhir:value "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication"];
  fhir:ValueSet.version [ fhir:value "1.1.0"];
  fhir:ValueSet.name [ fhir:value "C4BBAdjudication"];
  fhir:ValueSet.title [ fhir:value "C4BB Adjudication"];
  fhir:ValueSet.status [ fhir:value "active"];
  fhir:ValueSet.date [ fhir:value "2021-07-02T17:53:32+00:00"^^xsd:dateTime];
  fhir:ValueSet.publisher [ fhir:value "HL7 Financial Management Working Group"];
  fhir:ValueSet.contact [
     fhir:index 0;
     fhir:ContactDetail.name [ fhir:value "HL7 Financial Management Working Group" ];
     fhir:ContactDetail.telecom [
       fhir:index 0;
       fhir:ContactPoint.system [ fhir:value "url" ];
       fhir:ContactPoint.value [ fhir:value "http://www.hl7.org/Special/committees/fm/index.cfm" ]     ], [
       fhir:index 1;
       fhir:ContactPoint.system [ fhir:value "email" ];
       fhir:ContactPoint.value [ fhir:value "fm@lists.HL7.org" ]     ]
  ];
  fhir:ValueSet.description [ fhir:value "Describes the various amount fields used when payers receive and adjudicate a claim.  It includes the values \ndefined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem."];
  fhir:ValueSet.jurisdiction [
     fhir:index 0;
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "urn:iso:std:iso:3166" ];
       fhir:Coding.code [ fhir:value "US" ]     ]
  ];
  fhir:ValueSet.copyright [ fhir:value "This Valueset is not copyrighted."];
  fhir:ValueSet.compose [
     fhir:ValueSet.compose.include [
       fhir:index 0;
       fhir:ValueSet.compose.include.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ];
       fhir:ValueSet.compose.include.concept [
         fhir:index 0;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "submitted" ]       ], [
         fhir:index 1;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "copay" ]       ], [
         fhir:index 2;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "eligible" ]       ], [
         fhir:index 3;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "deductible" ]       ], [
         fhir:index 4;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "benefit" ]       ]     ], [
       fhir:index 1;
       fhir:ValueSet.compose.include.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ];
       fhir:ValueSet.compose.include.concept [
         fhir:index 0;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "coinsurance" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Coinsurance" ]       ], [
         fhir:index 1;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "noncovered" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Noncovered" ]       ], [
         fhir:index 2;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "priorpayerpaid" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Prior payer paid" ]       ], [
         fhir:index 3;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "paidbypatient" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Paid by patient" ]       ], [
         fhir:index 4;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "paidtopatient" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Paid to patient" ]       ], [
         fhir:index 5;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "paidtoprovider" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Paid to provider" ]       ], [
         fhir:index 6;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "memberliability" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Member liability" ]       ], [
         fhir:index 7;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "discount" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Discount" ]       ], [
         fhir:index 8;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "drugcost" ];
         fhir:ValueSet.compose.include.concept.display [ fhir:value "Drug cost" ]       ]     ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.