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

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: PDex Payer Adjudication Status - JSON Representation

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{
  "resourceType" : "CodeSystem",
  "id" : "PDexPayerAdjudicationStatus",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem PDexPayerAdjudicationStatus</b></p><a name=\"PDexPayerAdjudicationStatus\"> </a><a name=\"hcPDexPayerAdjudicationStatus\"> </a><a name=\"PDexPayerAdjudicationStatus-en-US\"> </a><p>This case-insensitive code system <code>http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus</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\">innetwork<a name=\"PDexPayerAdjudicationStatus-innetwork\"> </a></td><td>In Network</td><td>Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider</td></tr><tr><td style=\"white-space:nowrap\">outofnetwork<a name=\"PDexPayerAdjudicationStatus-outofnetwork\"> </a></td><td>Out Of Network</td><td>Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider</td></tr><tr><td style=\"white-space:nowrap\">other<a name=\"PDexPayerAdjudicationStatus-other\"> </a></td><td>Other</td><td>Indicates other network status or when a network does not apply</td></tr><tr><td style=\"white-space:nowrap\">contracted<a name=\"PDexPayerAdjudicationStatus-contracted\"> </a></td><td>Contracted</td><td>Indicates the provider was contracted for the service</td></tr><tr><td style=\"white-space:nowrap\">noncontracted<a name=\"PDexPayerAdjudicationStatus-noncontracted\"> </a></td><td>Non-Contracted</td><td>Indicates the provider was not contracted for the service</td></tr><tr><td style=\"white-space:nowrap\">paid<a name=\"PDexPayerAdjudicationStatus-paid\"> </a></td><td>Paid</td><td>Indicates if the claim was approved for payment</td></tr><tr><td style=\"white-space:nowrap\">denied<a name=\"PDexPayerAdjudicationStatus-denied\"> </a></td><td>Denied</td><td>Indicates if the claim was denied</td></tr><tr><td style=\"white-space:nowrap\">partiallypaid<a name=\"PDexPayerAdjudicationStatus-partiallypaid\"> </a></td><td>Partially Paid</td><td>Indicates that some line items on the claim were denied</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "fm"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus",
  "version" : "2.1.0-ballot",
  "name" : "PDexPayerAdjudicationStatus",
  "title" : "PDex Payer Adjudication Status",
  "status" : "active",
  "experimental" : false,
  "date" : "2024-08-14T20:04:35+00:00",
  "publisher" : "HL7 International / Financial Management",
  "contact" : [
    {
      "name" : "HL7 International / Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        },
        {
          "system" : "email",
          "value" : "fm@lists.HL7.org"
        }
      ]
    },
    {
      "name" : "Mark Scrimshire (mark.scrimshire@onyxhealth.io)",
      "telecom" : [
        {
          "system" : "email",
          "value" : "mailto:mark.scrimshire@onyxhealth.io"
        }
      ]
    },
    {
      "name" : "HL7 International - Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "description" : "Describes the various status fields used when payers adjudicate a claim, such as whether the claim was adjudicated in or out of network, if the provider was contracted or non-contracted for the service",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "copyright" : "This CodeSystem is not copyrighted.",
  "caseSensitive" : false,
  "content" : "complete",
  "count" : 8,
  "concept" : [
    {
      "code" : "innetwork",
      "display" : "In Network",
      "definition" : "Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider"
    },
    {
      "code" : "outofnetwork",
      "display" : "Out Of Network",
      "definition" : "Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider"
    },
    {
      "code" : "other",
      "display" : "Other",
      "definition" : "Indicates other network status or when a network does not apply"
    },
    {
      "code" : "contracted",
      "display" : "Contracted",
      "definition" : "Indicates the provider was contracted for the service"
    },
    {
      "code" : "noncontracted",
      "display" : "Non-Contracted",
      "definition" : "Indicates the provider was not contracted for the service"
    },
    {
      "code" : "paid",
      "display" : "Paid",
      "definition" : "Indicates if the claim was approved for payment"
    },
    {
      "code" : "denied",
      "display" : "Denied",
      "definition" : "Indicates if the claim was denied"
    },
    {
      "code" : "partiallypaid",
      "display" : "Partially Paid",
      "definition" : "Indicates that some line items on the claim were denied"
    }
  ]
}