{ "resourceType" : "ValueSet", "id" : "R5-v3-ActAdjudicationCode-for-R4", "text" : { "status" : "generated", "div" : "

Generated Narrative: ValueSet R5-v3-ActAdjudicationCode-for-R4

This value set expansion contains 13 concepts.

SystemVersionCodeDisplayDefinition
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0AAadjudicated with adjustments

The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges).

\n

Also includes the concept 'Adjudicate as zero' and items not covered under a particular Policy.

\n

Invoice element can be reversed (nullified).

\n

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0ANFadjudicated with adjustments and no financial impact

The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges) without changing the amount.

\n

Invoice element can be reversed (nullified).

\n

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0ARadjudicated as refused

The invoice element has passed through the adjudication process but payment is refused due to one or more reasons.

\n

Includes items such as patient not covered, or invoice element is not constructed according to payer rules (e.g. 'invoice submitted too late').

\n

If one invoice element line item in the invoice element structure is rejected, the remaining line items may not be adjudicated and the complete group is treated as rejected.

\n

A refused invoice element can be forwarded to the next payer (for Coordination of Benefits) or modified and resubmitted to refusing payer.

\n

Invoice element cannot be reversed (nullified) as there is nothing to reverse.

\n

Recommend that the invoice element is not saved for DUR (Drug Utilization Reporting).

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0ASadjudicated as submitted

The invoice element was/will be paid exactly as submitted, without financial adjustment(s).

\n

If the dollar amount stays the same, but the billing codes have been amended or financial adjustments have been applied through the adjudication process, the invoice element is treated as "Adjudicated with Adjustment".

\n

If information items are included in the adjudication results that do not affect the monetary amounts paid, then this is still Adjudicated as Submitted (e.g. 'reached Plan Maximum on this Claim').

\n

Invoice element can be reversed (nullified).

\n

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0CONTcontract

Transaction counts and value totals by Contract Identifier.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0DAYday

Transaction counts and value totals for each calendar day within the date range specified.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0LOClocation

Transaction counts and value totals by service location (e.g clinic).

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0MONTHmonth

Transaction counts and value totals for each calendar month within the date range specified.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0PERIODperiod

Transaction counts and value totals for the date range specified.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0PROVprovider

Transaction counts and value totals by Provider Identifier.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0WEEKweek

Transaction counts and value totals for each calendar week within the date range specified.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0YEARyear

Transaction counts and value totals for each calendar year within the date range specified.

\n
http://terminology.hl7.org/CodeSystem/v3-ActCode8.0.0\u00a0\u00a0_ActAdjudicationGroupCodeActAdjudicationGroupCode

Catagorization of grouping criteria for the associated transactions and/or summary (totals, subtotals).

\n
" }, "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg", "valueCode" : "fhir" }, { "extension" : [{ "url" : "packageId", "valueId" : "hl7.fhir.uv.xver-r5.r4" }, { "url" : "version", "valueString" : "0.1.0" }, { "url" : "uri", "valueUri" : "http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4" }], "url" : "http://hl7.org/fhir/StructureDefinition/package-source" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger" : 0, "_valueInteger" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom", "valueCanonical" : "http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4" }] } }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status", "valueCode" : "trial-use", "_valueCode" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom", "valueCanonical" : "http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4" }] } }], "url" : "http://hl7.org/fhir/uv/xver/ValueSet/R5-v3-ActAdjudicationCode-for-R4", "version" : "0.1.0", "name" : "R5V3ActAdjudicationCodeForR4", "title" : "Cross-version ValueSet R5.ActAdjudicationCode for use in FHIR R4", "status" : "active", "experimental" : false, "date" : "2026-03-17T21:02:03.8104715+00:00", "publisher" : "FHIR Infrastructure", "contact" : [{ "name" : "FHIR Infrastructure", "telecom" : [{ "system" : "url", "value" : "http://www.hl7.org/Special/committees/fiwg" }] }], "description" : "This cross-version ValueSet represents content from `http://terminology.hl7.org/ValueSet/v3-ActAdjudicationCode|2.0.0` for use in FHIR R4.", "jurisdiction" : [{ "coding" : [{ "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm", "code" : "001", "display" : "World" }] }], "purpose" : "This value set is part of the cross-version definitions generated to enable use of the\r\nvalue set `http://terminology.hl7.org/ValueSet/v3-ActAdjudicationCode|2.0.0` as defined in FHIR R5\r\nin FHIR R4.\r\n\r\nThe source value set is bound to the following FHIR R5 elements:\r\n* \r\n\r\nNote that all concepts are included in this cross-version definition because no concepts have compatible representations\r\n\r\nFollowing are the generation technical comments:\r\n\nFHIR ValueSet `http://terminology.hl7.org/ValueSet/v3-ActAdjudicationCode|2.0.0`, defined in FHIR R5 does not have any mapping to FHIR R4", "compose" : { "include" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "concept" : [{ "code" : "AA", "display" : "adjudicated with adjustments" }, { "code" : "ANF", "display" : "adjudicated with adjustments and no financial impact" }, { "code" : "AR", "display" : "adjudicated as refused" }, { "code" : "AS", "display" : "adjudicated as submitted" }, { "code" : "CONT", "display" : "contract" }, { "code" : "DAY", "display" : "day" }, { "code" : "LOC", "display" : "location" }, { "code" : "MONTH", "display" : "month" }, { "code" : "PERIOD", "display" : "period" }, { "code" : "PROV", "display" : "provider" }, { "code" : "WEEK", "display" : "week" }, { "code" : "YEAR", "display" : "year" }, { "code" : "_ActAdjudicationGroupCode", "display" : "ActAdjudicationGroupCode" }] }] }, "expansion" : { "timestamp" : "2026-03-17T21:02:03.8104715+00:00", "contains" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "AA", "display" : "adjudicated with adjustments" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "ANF", "display" : "adjudicated with adjustments and no financial impact" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "AR", "display" : "adjudicated as refused" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "AS", "display" : "adjudicated as submitted" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "CONT", "display" : "contract" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "DAY", "display" : "day" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "LOC", "display" : "location" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "MONTH", "display" : "month" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "PERIOD", "display" : "period" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "PROV", "display" : "provider" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "WEEK", "display" : "week" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "YEAR", "display" : "year" }, { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "version" : "8.0.0", "code" : "_ActAdjudicationGroupCode", "display" : "ActAdjudicationGroupCode" }] } }