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
Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication | Version: 2.0.0-ballot | |||
Standards status: Trial-use | Computable Name: PCTAdjudication | |||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.48.6 | ||||
Copyright/Legal: This Valueset is not copyrighted. |
Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.
References
This value set includes codes based on the following rules:
http://terminology.hl7.org/CodeSystem/adjudication
Code | Display | Definition |
submitted | Submitted Amount | The total submitted amount for the claim or group or line item. |
copay | CoPay | Patient Co-Payment |
eligible | Eligible Amount | Amount of the change which is considered for adjudication. |
deductible | Deductible | Amount deducted from the eligible amount prior to adjudication. |
benefit | Benefit Amount | Amount payable under the coverage |
http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
Code | Display | Definition |
coinsurance | 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 | 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 |
Expansion based on:
This value set contains 9 concepts.
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/davinci-pct/CodeSystem/PCTAdjudication | 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/davinci-pct/CodeSystem/PCTAdjudication | 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 | http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | Member liability | The amount of the member's liability. |
discount | http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | Discount | The amount of the discount |
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 |
System | 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 |