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 - XML Representation
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<CodeSystem xmlns="http://hl7.org/fhir">
<id value="PCTFinancialType"/>
<text>
<status value="generated"/>
<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>
</text>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
<valueCode value="fm"/>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
<valueCode value="trial-use">
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
<valueCanonical
value="http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"/>
</extension>
</valueCode>
</extension>
<url
value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"/>
<version value="1.1.0"/>
<name value="PCTFinancialType"/>
<title value="PCT Financial Type Code System"/>
<status value="active"/>
<experimental value="false"/>
<date value="2024-01-03T18:32:02+00:00"/>
<publisher value="HL7 International / Financial Management"/>
<contact>
<name value="HL7 International / Financial Management"/>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/fm"/>
</telecom>
<telecom>
<system value="email"/>
<value value="fmlists@lists.hl7.org"/>
</telecom>
</contact>
<description
value="Financial Type codes for benefitBalance.financial.type."/>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
</coding>
</jurisdiction>
<copyright value="This CodeSystem is not copyrighted."/>
<caseSensitive value="true"/>
<content value="complete"/>
<count value="10"/>
<concept>
<code value="allowed"/>
<display value="Allowed"/>
<definition
value="The maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate"."/>
</concept>
<concept>
<code value="coinsurance"/>
<display value="Co-Insurance"/>
<definition
value="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%."/>
</concept>
<concept>
<code value="copay"/>
<display value="CoPay"/>
<definition
value="A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid."/>
</concept>
<concept>
<code value="deductible"/>
<display value="Deductible"/>
<definition
value="The amount the insured individual pays for covered health care services before the insurance plan starts to pay."/>
</concept>
<concept>
<code value="eligible"/>
<display value="Eligible Amount"/>
<definition
value="Amount of the charge which is considered for adjudication."/>
</concept>
<concept>
<code value="memberliability"/>
<display value="Member Liability"/>
<definition value="The amount of the member's liability."/>
</concept>
<concept>
<code value="noncovered"/>
<display value="Noncovered"/>
<definition
value="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."/>
</concept>
<concept>
<code value="out-of-pocket-maximum"/>
<display value="Out-of-Pocket Maximum"/>
<definition
value="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."/>
</concept>
<concept>
<code value="visit"/>
<display value="Visit"/>
<definition
value="A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting."/>
</concept>
<concept>
<code value="penalty"/>
<display value="Penalty"/>
<definition
value="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."/>
</concept>
</CodeSystem>
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