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 - XML Representation
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<ValueSet xmlns="http://hl7.org/fhir">
<id value="PDexAdjudication"/>
<text>
<status value="extensions"/>
<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>
</text>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
<valueCode value="fm"/>
</extension>
<url value="http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication"/>
<version value="2.0.0"/>
<name value="PDexAdjudication"/>
<title value="PDex Adjudication"/>
<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 amount fields used when payers receive and adjudicate a claim. It includes the values
defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the PDex Adjudication CodeSystem."/>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
<display value="United States of America"/>
</coding>
</jurisdiction>
<copyright value="This Valueset is not copyrighted."/>
<compose>
<include>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<concept>
<code value="submitted"/>
</concept>
<concept>
<code value="copay"/>
</concept>
<concept>
<code value="eligible"/>
</concept>
<concept>
<code value="deductible"/>
</concept>
<concept>
<code value="benefit"/>
</concept>
</include>
<include>
<system
value="http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS"/>
<concept>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</concept>
<concept>
<code value="noncovered"/>
<display value="Noncovered"/>
</concept>
<concept>
<code value="priorpayerpaid"/>
<display value="Prior payer paid"/>
</concept>
<concept>
<code value="paidbypatient"/>
<display value="Paid by patient"/>
</concept>
<concept>
<code value="paidtopatient"/>
<display value="Paid to patient"/>
</concept>
<concept>
<code value="paidtoprovider"/>
<display value="Paid to provider"/>
</concept>
<concept>
<code value="memberliability"/>
<display value="Member liability"/>
</concept>
<concept>
<code value="discount"/>
<display value="Discount"/>
</concept>
<concept>
<code value="drugcost"/>
<display value="Drug cost"/>
</concept>
</include>
</compose>
</ValueSet>
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