Patient Cost Transparency Implementation Guide
0.1.0 - STU 1 Ballot

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v0.1.0: STU 1 Draft) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

ValueSet: PCT GFE Item Adjudication Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set

Summary

Defining URL:http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemAdjudicationVS
Version:0.1.0
Name:PCTGFEItemAdjudicationVS
Title:PCT GFE Item Adjudication Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set
Status:Active as of 12/4/21 9:54 PM
Definition:

Sample Adjudication codes to indicate the amounts eligible under the plan, the amount of benefit, copays etc.

Publisher:HL7 International - Financial Management Work 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:

 

Expansion

This value set contains 17 concepts

CodeSystemDisplayDefinition
submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted AmountThe total submitted amount for the claim or group or line item.
copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPayPatient Co-Payment
eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible AmountAmount of the change which is considered for adjudication.
deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductibleAmount deducted from the eligible amount prior to adjudication.
unallocdeducthttp://terminology.hl7.org/CodeSystem/adjudicationUnallocated DeductibleThe amount of deductible which could not allocated to other line items.
eligpercenthttp://terminology.hl7.org/CodeSystem/adjudicationEligible %Eligible Percentage.
taxhttp://terminology.hl7.org/CodeSystem/adjudicationTaxThe amount of tax.
benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit AmountAmount payable under the coverage
coinsurancehttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypeCo-insuranceThe 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%.
noncoveredhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypeNoncoveredThe 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.
priorpayerpaidhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypePrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
paidbypatienthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypePaid by patientThe amount paid by the patient at the point of service.
paidtoproviderhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypePaid to providerThe amount paid to the provider.
paidtopatienthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypePaid to patientpaid to patient
memberliabilityhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypeMember liabilityThe amount of the member's liability.
discounthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypeDiscountThe amount of the discount
drugcosthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryTypeDrug costPrice 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

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