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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
: PDex Adjudication Codes - XML Representation
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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>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>
<url
value="http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS"/>
<version value="2.0.0"/>
<name value="PDexAdjudicationCS"/>
<title value="PDex Adjudication Codes"/>
<status value="active"/>
<experimental value="true"/>
<date value="2024-01-06T03:07:01+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>
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