Da Vinci Payer Data Exchange
2.0.0-ballot - ballot US

This page is part of the Da Vinci Payer Data Exchange (v2.0.0-ballot: STU2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

ValueSet: PDex Adjudication Category Discriminator

Official URL: http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator Version: 2.0.0-ballot
Active as of 2022-02-18 Computable Name: PDexAdjudicationCategoryDiscriminator

Copyright/Legal: This Valueset is not copyrighted.

Used as the discriminator for adjudication.category and item.adjudication.category for the PDex Prior Authorization

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

 

Expansion

This value set contains 20 concepts

CodeSystemDisplayDefinition
submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted AmountThe total submitted amount for the claim or group or line item.
copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPayPatient Co-Payment
eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible AmountAmount of the change which is considered for adjudication.
deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductibleAmount deducted from the eligible amount prior to adjudication.
benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit AmountAmount payable under the coverage
coinsurancehttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSCoinsuranceThe 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%.
noncoveredhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSNoncoveredThe 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.
priorpayerpaidhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
paidbypatienthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPaid by patientThe amount paid by the patient at the point of service.
paidtopatienthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPaid to patientpaid to patient
paidtoproviderhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPaid to providerThe amount paid to the provider.
memberliabilityhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSMember liabilityThe amount of the member's liability.
discounthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSDiscountThe amount of the discount
drugcosthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSDrug costPrice paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration
innetworkhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatusIn NetworkIndicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
outofnetworkhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatusOut Of NetworkIndicates the claim or claim line was paid out of network. This does not indicate the contracting status of the provider
otherhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatusOtherIndicates other network status or when a network does not apply
allowedunitshttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminatorallowed unitsdefines the adjudication slice to define allowed units
consumedunitshttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminatorconsumed unitsdefines the adjudication slice to define consumed units
denialreasonhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminatorDenial Reasondefines the adjudication slice to identify the denial reason

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