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
| Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication | Version: 1.1.0 | |||
| Standards status: Trial-use | Computable Name: PCTAdjudication | |||
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 |