Patient Cost Transparency Implementation Guide
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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 Adjudication Value Set - XML Representation

Page standards status: Trial-use

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<ValueSet xmlns="http://hl7.org/fhir">
  <id value="PCTAdjudication"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p>This value set includes codes based on the following rules:</p><ul><li>Include these codes as defined in <a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><table class="none"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html#adjudication-submitted">submitted</a></td><td style="color: #cccccc">Submitted Amount</td><td>The total submitted amount for the claim or group or line item.</td></tr><tr><td><a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html#adjudication-copay">copay</a></td><td style="color: #cccccc">CoPay</td><td>Patient Co-Payment</td></tr><tr><td><a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html#adjudication-eligible">eligible</a></td><td style="color: #cccccc">Eligible Amount</td><td>Amount of the change which is considered for adjudication.</td></tr><tr><td><a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html#adjudication-deductible">deductible</a></td><td style="color: #cccccc">Deductible</td><td>Amount deducted from the eligible amount prior to adjudication.</td></tr><tr><td><a href="http://terminology.hl7.org/5.3.0/CodeSystem-adjudication.html#adjudication-benefit">benefit</a></td><td style="color: #cccccc">Benefit Amount</td><td>Amount payable under the coverage</td></tr></table></li><li>Include these codes as defined in <a href="CodeSystem-PCTAdjudication.html"><code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication</code></a><table class="none"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href="CodeSystem-PCTAdjudication.html#PCTAdjudication-coinsurance">coinsurance</a></td><td>Coinsurance</td><td>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%.</td></tr><tr><td><a href="CodeSystem-PCTAdjudication.html#PCTAdjudication-noncovered">noncovered</a></td><td>Noncovered</td><td>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.</td></tr><tr><td><a href="CodeSystem-PCTAdjudication.html#PCTAdjudication-memberliability">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href="CodeSystem-PCTAdjudication.html#PCTAdjudication-discount">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr></table></li></ul></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/ValueSet/PCTAdjudication"/>
  <version value="1.1.0"/>
  <name value="PCTAdjudication"/>
  <title value="PCT Adjudication Value Set"/>
  <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="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."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
    </coding>
  </jurisdiction>
  <copyright value="This Valueset is not copyrighted."/>
  <compose>
    <include>
      <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
      <concept>
        <code value="submitted"/>
      </concept>
      <concept>
        <code value="copay"/>
      </concept>
      <concept>
        <code value="eligible"/>
      </concept>
      <concept>
        <code value="deductible"/>
      </concept>
      <concept>
        <code value="benefit"/>
      </concept>
    </include>
    <include>
      <system
              value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication"/>
      <concept>
        <code value="coinsurance"/>
        <display value="Coinsurance"/>
      </concept>
      <concept>
        <code value="noncovered"/>
        <display value="Noncovered"/>
      </concept>
      <concept>
        <code value="memberliability"/>
        <display value="Member liability"/>
      </concept>
      <concept>
        <code value="discount"/>
        <display value="Discount"/>
      </concept>
    </include>
  </compose>
</ValueSet>