This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v1.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
: PCT Financial Type Code System - JSON Representation
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{
"resourceType" : "CodeSystem",
"id" : "PCTFinancialType",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">allowed<a name=\"PCTFinancialType-allowed\"> </a></td><td>Allowed</td><td>The maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".</td></tr><tr><td style=\"white-space:nowrap\">coinsurance<a name=\"PCTFinancialType-coinsurance\"> </a></td><td>Co-Insurance</td><td>The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.</td></tr><tr><td style=\"white-space:nowrap\">copay<a name=\"PCTFinancialType-copay\"> </a></td><td>CoPay</td><td>A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.</td></tr><tr><td style=\"white-space:nowrap\">deductible<a name=\"PCTFinancialType-deductible\"> </a></td><td>Deductible</td><td>The amount the insured individual pays for covered health care services before the insurance plan starts to pay.</td></tr><tr><td style=\"white-space:nowrap\">eligible<a name=\"PCTFinancialType-eligible\"> </a></td><td>Eligible Amount</td><td>Amount of the charge which is considered for adjudication.</td></tr><tr><td style=\"white-space:nowrap\">memberliability<a name=\"PCTFinancialType-memberliability\"> </a></td><td>Member Liability</td><td>The amount of the member's liability.</td></tr><tr><td style=\"white-space:nowrap\">noncovered<a name=\"PCTFinancialType-noncovered\"> </a></td><td>Noncovered</td><td>The portion of the cost of the 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 style=\"white-space:nowrap\">out-of-pocket-maximum<a name=\"PCTFinancialType-out-of-pocket-maximum\"> </a></td><td>Out-of-Pocket Maximum</td><td>The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits.</td></tr><tr><td style=\"white-space:nowrap\">visit<a name=\"PCTFinancialType-visit\"> </a></td><td>Visit</td><td>A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.</td></tr><tr><td style=\"white-space:nowrap\">penalty<a name=\"PCTFinancialType-penalty\"> </a></td><td>Penalty</td><td>Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example.</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode" : "trial-use",
"_valueCode" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType",
"version" : "1.1.0",
"name" : "PCTFinancialType",
"title" : "PCT Financial Type Code System",
"status" : "active",
"experimental" : false,
"date" : "2024-01-03T18:32:02+00:00",
"publisher" : "HL7 International / Financial Management",
"contact" : [
{
"name" : "HL7 International / Financial Management",
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/fm"
},
{
"system" : "email",
"value" : "fmlists@lists.hl7.org"
}
]
}
],
"description" : "Financial Type codes for benefitBalance.financial.type.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"copyright" : "This CodeSystem is not copyrighted.",
"caseSensitive" : true,
"content" : "complete",
"count" : 10,
"concept" : [
{
"code" : "allowed",
"display" : "Allowed",
"definition" : "The maximum amount a plan will pay for a covered health care service. May also be called \"payment allowance\", or \"negotiated rate\"."
},
{
"code" : "coinsurance",
"display" : "Co-Insurance",
"definition" : "The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%."
},
{
"code" : "copay",
"display" : "CoPay",
"definition" : "A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid."
},
{
"code" : "deductible",
"display" : "Deductible",
"definition" : "The amount the insured individual pays for covered health care services before the insurance plan starts to pay."
},
{
"code" : "eligible",
"display" : "Eligible Amount",
"definition" : "Amount of the charge which is considered for adjudication."
},
{
"code" : "memberliability",
"display" : "Member Liability",
"definition" : "The amount of the member's liability."
},
{
"code" : "noncovered",
"display" : "Noncovered",
"definition" : "The portion of the cost of the service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."
},
{
"code" : "out-of-pocket-maximum",
"display" : "Out-of-Pocket Maximum",
"definition" : "The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits."
},
{
"code" : "visit",
"display" : "Visit",
"definition" : "A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting."
},
{
"code" : "penalty",
"display" : "Penalty",
"definition" : "Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example."
}
]
}
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