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 - JSON Representation
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{
"resourceType" : "ValueSet",
"id" : "PDexAdjudication",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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/5.0.0/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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
}
],
"url" : "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication",
"version" : "2.0.0",
"name" : "PDexAdjudication",
"title" : "PDex Adjudication",
"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 includes the values\ndefined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the PDex Adjudication CodeSystem.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US",
"display" : "United States of America"
}
]
}
],
"copyright" : "This Valueset is not copyrighted.",
"compose" : {
"include" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"concept" : [
{
"code" : "submitted"
},
{
"code" : "copay"
},
{
"code" : "eligible"
},
{
"code" : "deductible"
},
{
"code" : "benefit"
}
]
},
{
"system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS",
"concept" : [
{
"code" : "coinsurance",
"display" : "Coinsurance"
},
{
"code" : "noncovered",
"display" : "Noncovered"
},
{
"code" : "priorpayerpaid",
"display" : "Prior payer paid"
},
{
"code" : "paidbypatient",
"display" : "Paid by patient"
},
{
"code" : "paidtopatient",
"display" : "Paid to patient"
},
{
"code" : "paidtoprovider",
"display" : "Paid to provider"
},
{
"code" : "memberliability",
"display" : "Member liability"
},
{
"code" : "discount",
"display" : "Discount"
},
{
"code" : "drugcost",
"display" : "Drug cost"
}
]
}
]
}
}
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