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 - TTL Representation
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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ValueSet ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "PDexAdjudication"] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet PDexAdjudication</b></p><a name=\"PDexAdjudication\"> </a><a name=\"hcPDexAdjudication\"> </a><a name=\"PDexAdjudication-en-US\"> </a><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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/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-PDexAdjudicationCS.html\"><code>http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS</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-PDexAdjudicationCS.html#PDexAdjudicationCS-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-PDexAdjudicationCS.html#PDexAdjudicationCS-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-PDexAdjudicationCS.html#PDexAdjudicationCS-priorpayerpaid\">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><a href=\"CodeSystem-PDexAdjudicationCS.html#PDexAdjudicationCS-paidbypatient\">paidbypatient</a></td><td>Paid by patient</td><td>The amount paid by the patient at the point of service.</td></tr><tr><td><a href=\"CodeSystem-PDexAdjudicationCS.html#PDexAdjudicationCS-paidtopatient\">paidtopatient</a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td><a href=\"CodeSystem-PDexAdjudicationCS.html#PDexAdjudicationCS-paidtoprovider\">paidtoprovider</a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td><a href=\"CodeSystem-PDexAdjudicationCS.html#PDexAdjudicationCS-memberliability\">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href=\"CodeSystem-PDexAdjudicationCS.html#PDexAdjudicationCS-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td><a href=\"CodeSystem-PDexAdjudicationCS.html#PDexAdjudicationCS-drugcost\">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></li></ul></div>"
] ; #
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ;
fhir:value [ fhir:v "fm" ]
] [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ] ;
fhir:value [
fhir:v "informative" ;
( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ] ;
fhir:value [
fhir:v "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex> ] ] ) ]
] ) ; #
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication"^^xsd:anyURI] ; #
fhir:version [ fhir:v "2.1.0-ballot"] ; #
fhir:name [ fhir:v "PDexAdjudication"] ; #
fhir:title [ fhir:v "PDex Adjudication"] ; #
fhir:status [ fhir:v "active"] ; #
fhir:experimental [ fhir:v "true"^^xsd:boolean] ; #
fhir:date [ fhir:v "2024-08-14T20:04:35+00:00"^^xsd:dateTime] ; #
fhir:publisher [ fhir:v "HL7 International / Financial Management"] ; #
fhir:contact ( [
fhir:name [ fhir:v "HL7 International / Financial Management" ] ;
( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ] ] [
fhir:system [ fhir:v "email" ] ;
fhir:value [ fhir:v "fm@lists.HL7.org" ] ] )
] [
fhir:name [ fhir:v "Mark Scrimshire (mark.scrimshire@onyxhealth.io)" ] ;
( fhir:telecom [
fhir:system [ fhir:v "email" ] ;
fhir:value [ fhir:v "mailto:mark.scrimshire@onyxhealth.io" ] ] )
] [
fhir:name [ fhir:v "HL7 International - Financial Management" ] ;
( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ] ] )
] ) ; #
fhir:description [ fhir:v "Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values\ndefined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the PDex Adjudication CodeSystem."] ; #
fhir:jurisdiction ( [
( fhir:coding [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "US" ] ;
fhir:display [ fhir:v "United States of America" ] ] )
] ) ; #
fhir:copyright [ fhir:v "This Valueset is not copyrighted."] ; #
fhir:compose [
( fhir:include [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
( fhir:concept [
fhir:code [ fhir:v "submitted" ] ] [
fhir:code [ fhir:v "copay" ] ] [
fhir:code [ fhir:v "eligible" ] ] [
fhir:code [ fhir:v "deductible" ] ] [
fhir:code [ fhir:v "benefit" ] ] ) ] [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS"^^xsd:anyURI ] ;
( fhir:concept [
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Coinsurance" ] ] [
fhir:code [ fhir:v "noncovered" ] ;
fhir:display [ fhir:v "Noncovered" ] ] [
fhir:code [ fhir:v "priorpayerpaid" ] ;
fhir:display [ fhir:v "Prior payer paid" ] ] [
fhir:code [ fhir:v "paidbypatient" ] ;
fhir:display [ fhir:v "Paid by patient" ] ] [
fhir:code [ fhir:v "paidtopatient" ] ;
fhir:display [ fhir:v "Paid to patient" ] ] [
fhir:code [ fhir:v "paidtoprovider" ] ;
fhir:display [ fhir:v "Paid to provider" ] ] [
fhir:code [ fhir:v "memberliability" ] ;
fhir:display [ fhir:v "Member liability" ] ] [
fhir:code [ fhir:v "discount" ] ;
fhir:display [ fhir:v "Discount" ] ] [
fhir:code [ fhir:v "drugcost" ] ;
fhir:display [ fhir:v "Drug cost" ] ] ) ] )
] . #
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