Da Vinci Payer Data Exchange
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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 Payer Adjudication Status - XML Representation

Active as of 2024-01-06

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="PDexPayerAdjudicationStatus"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><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>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fm"/>
  </extension>
  <url
       value="http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus"/>
  <version value="2.0.0"/>
  <name value="PDexPayerAdjudicationStatus"/>
  <title value="PDex Payer Adjudication Status"/>
  <status value="active"/>
  <experimental value="true"/>
  <date value="2024-01-06T03:22:26+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 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 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="8"/>
  <concept>
    <code value="innetwork"/>
    <display value="In Network"/>
    <definition
                value="Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider"/>
  </concept>
  <concept>
    <code value="outofnetwork"/>
    <display value="Out Of Network"/>
    <definition
                value="Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider"/>
  </concept>
  <concept>
    <code value="other"/>
    <display value="Other"/>
    <definition
                value="Indicates other network status or when a network does not apply"/>
  </concept>
  <concept>
    <code value="contracted"/>
    <display value="Contracted"/>
    <definition
                value="Indicates the provider was contracted for the service"/>
  </concept>
  <concept>
    <code value="noncontracted"/>
    <display value="Non-Contracted"/>
    <definition
                value="Indicates the provider was not contracted for the service"/>
  </concept>
  <concept>
    <code value="paid"/>
    <display value="Paid"/>
    <definition value="Indicates if the claim was approved for payment"/>
  </concept>
  <concept>
    <code value="denied"/>
    <display value="Denied"/>
    <definition value="Indicates if the claim was denied"/>
  </concept>
  <concept>
    <code value="partiallypaid"/>
    <display value="Partially Paid"/>
    <definition
                value="Indicates that some line items on the claim were denied"/>
  </concept>
</CodeSystem>