Da Vinci Payer Data Exchange
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This page is part of the Da Vinci Payer Data Exchange (v2.1.0-ballot: STU2.1 Ballot 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

: PDex Adjudication Codes - XML Representation

Page standards status: Trial-use

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="PDexAdjudicationCS"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem PDexAdjudicationCS</b></p><a name="PDexAdjudicationCS"> </a><a name="hcPDexAdjudicationCS"> </a><a name="PDexAdjudicationCS-en-US"> </a><p>This case-insensitive code system <code>http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS</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">coinsurance<a name="PDexAdjudicationCS-coinsurance"> </a></td><td>Co-insurance</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 style="white-space:nowrap">noncovered<a name="PDexAdjudicationCS-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 style="white-space:nowrap">priorpayerpaid<a name="PDexAdjudicationCS-priorpayerpaid"> </a></td><td>Prior payer paid</td><td>The reduction in the payment amount to reflect the carrier as a secondary payor.</td></tr><tr><td style="white-space:nowrap">paidbypatient<a name="PDexAdjudicationCS-paidbypatient"> </a></td><td>Paid by patient</td><td>The amount paid by the patient at the point of service.</td></tr><tr><td style="white-space:nowrap">paidtoprovider<a name="PDexAdjudicationCS-paidtoprovider"> </a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td style="white-space:nowrap">paidtopatient<a name="PDexAdjudicationCS-paidtopatient"> </a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td style="white-space:nowrap">memberliability<a name="PDexAdjudicationCS-memberliability"> </a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td style="white-space:nowrap">discount<a name="PDexAdjudicationCS-discount"> </a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td style="white-space:nowrap">drugcost<a name="PDexAdjudicationCS-drugcost"> </a></td><td>Drug cost</td><td>Price 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</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-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS"/>
  <version value="2.1.0-ballot"/>
  <name value="PDexAdjudicationCS"/>
  <title value="PDex Adjudication Codes"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2024-08-14T20:04:35+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="fm@lists.HL7.org"/>
    </telecom>
  </contact>
  <contact>
    <name value="Mark Scrimshire (mark.scrimshire@onyxhealth.io)"/>
    <telecom>
      <system value="email"/>
      <value value="mailto:mark.scrimshire@onyxhealth.io"/>
    </telecom>
  </contact>
  <contact>
    <name value="HL7 International - Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
  </contact>
  <description
               value="Describes the various amount fields used when payers receive and adjudicate a claim.  It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
  </jurisdiction>
  <copyright value="This CodeSystem is not copyrighted."/>
  <caseSensitive value="false"/>
  <content value="complete"/>
  <count value="9"/>
  <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 medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%."/>
  </concept>
  <concept>
    <code value="noncovered"/>
    <display value="Noncovered"/>
    <definition
                value="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."/>
  </concept>
  <concept>
    <code value="priorpayerpaid"/>
    <display value="Prior payer paid"/>
    <definition
                value="The reduction in the payment amount to reflect the carrier as a secondary payor."/>
  </concept>
  <concept>
    <code value="paidbypatient"/>
    <display value="Paid by patient"/>
    <definition
                value="The amount paid by the patient at the point of service."/>
  </concept>
  <concept>
    <code value="paidtoprovider"/>
    <display value="Paid to provider"/>
    <definition value="The amount paid to the provider."/>
  </concept>
  <concept>
    <code value="paidtopatient"/>
    <display value="Paid to patient"/>
    <definition value="paid to patient"/>
  </concept>
  <concept>
    <code value="memberliability"/>
    <display value="Member liability"/>
    <definition value="The amount of the member's liability."/>
  </concept>
  <concept>
    <code value="discount"/>
    <display value="Discount"/>
    <definition value="The amount of the discount"/>
  </concept>
  <concept>
    <code value="drugcost"/>
    <display value="Drug cost"/>
    <definition
                value="Price 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"/>
  </concept>
</CodeSystem>