Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot US

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

CodeSystem: PCT Adjudication Code System

Official URL: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication Version: 2.0.0-ballot
Standards status: Trial-use Computable Name: PCTAdjudication
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.16.2

Copyright/Legal: This CodeSystem is not copyrighted.

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

This Code system is referenced in the content logical definition of the following value sets:

This case-sensitive code system http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication defines the following codes:

CodeDisplayDefinition
coinsurance Co-insurance 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 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.
memberliability Member liability The amount of the member's liability.
discount Discount The amount of the discount