Patient Cost Transparency Implementation Guide
1.0.0 - STU 1 United States of America flag

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v1.0.0: STU 1) 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

CodeSystem: PCT Financial Type Code System

Official URL: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType Version: 1.0.0
Active as of 2023-03-30 Computable Name: PCTFinancialType

Copyright/Legal: This CodeSystem is not copyrighted.

Financial Type codes for benefitBalance.financial.type.

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

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

CodeDisplayDefinition
allowed AllowedThe maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".
coinsurance Co-InsuranceThe 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%.
copay CoPayA fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.
deductible DeductibleThe amount the insured individual pays for covered health care services before the insurance plan starts to pay.
eligible Eligible AmountAmount of the charge which is considered for adjudication.
memberliability Member LiabilityThe amount of the member's liability.
noncovered NoncoveredThe 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.
out-of-pocket-maximum Out-of-Pocket MaximumThe 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.
visit VisitA medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.
penalty PenaltyBenefit 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.