This page is part of the Da Vinci Payer Data Exchange (v2.0.0: STU2) 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
: PDex Adjudication Codes - JSON Representation
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{
"resourceType" : "CodeSystem",
"id" : "PDexAdjudicationCS",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
}
],
"url" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS",
"version" : "2.0.0",
"name" : "PDexAdjudicationCS",
"title" : "PDex Adjudication Codes",
"status" : "active",
"experimental" : true,
"date" : "2024-01-06T03:22:26+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 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" : "urn:iso:std:iso:3166",
"code" : "US",
"display" : "United States of America"
}
]
}
],
"copyright" : "This CodeSystem is not copyrighted.",
"caseSensitive" : false,
"content" : "complete",
"count" : 9,
"concept" : [
{
"code" : "coinsurance",
"display" : "Co-insurance",
"definition" : "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%."
},
{
"code" : "noncovered",
"display" : "Noncovered",
"definition" : "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."
},
{
"code" : "priorpayerpaid",
"display" : "Prior payer paid",
"definition" : "The reduction in the payment amount to reflect the carrier as a secondary payor."
},
{
"code" : "paidbypatient",
"display" : "Paid by patient",
"definition" : "The amount paid by the patient at the point of service."
},
{
"code" : "paidtoprovider",
"display" : "Paid to provider",
"definition" : "The amount paid to the provider."
},
{
"code" : "paidtopatient",
"display" : "Paid to patient",
"definition" : "paid to patient"
},
{
"code" : "memberliability",
"display" : "Member liability",
"definition" : "The amount of the member's liability."
},
{
"code" : "discount",
"display" : "Discount",
"definition" : "The amount of the discount"
},
{
"code" : "drugcost",
"display" : "Drug cost",
"definition" : "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"
}
]
}
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