Extensions for Using Data Elements from FHIR R5 in FHIR R4
0.1.0 - STU International flag

Extensions for Using Data Elements from FHIR R5 in FHIR R4 - Downloaded Version null See the Directory of published versions

: R5V3ActAdjudicationCodeForR4 - XML Representation

Page standards status: Trial-use Maturity Level: 0

Raw xml | Download


<ValueSet xmlns="http://hl7.org/fhir">
  <id value="R5-v3-ActAdjudicationCode-for-R4"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ValueSet R5-v3-ActAdjudicationCode-for-R4</b></p><a name="R5-v3-ActAdjudicationCode-for-R4"> </a><a name="hcR5-v3-ActAdjudicationCode-for-R4"> </a><p>This value set expansion contains 13 concepts.</p><table class="codes"><tr><td><b>System</b></td><td><b>Version</b></td><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-AA"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-AA">AA</a></td><td>adjudicated with adjustments</td><td><div><p>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).</p>
<p>Also includes the concept 'Adjudicate as zero' and items not covered under a particular Policy.</p>
<p>Invoice element can be reversed (nullified).</p>
<p>Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-ANF"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-ANF">ANF</a></td><td>adjudicated with adjustments and no financial impact</td><td><div><p>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.</p>
<p>Invoice element can be reversed (nullified).</p>
<p>Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-AR"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-AR">AR</a></td><td>adjudicated as refused</td><td><div><p>The invoice element has passed through the adjudication process but payment is refused due to one or more reasons.</p>
<p>Includes items such as patient not covered, or invoice element is not constructed according to payer rules (e.g. 'invoice submitted too late').</p>
<p>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.</p>
<p>A refused invoice element can be forwarded to the next payer (for Coordination of Benefits) or modified and resubmitted to refusing payer.</p>
<p>Invoice element cannot be reversed (nullified) as there is nothing to reverse.</p>
<p>Recommend that the invoice element is not saved for DUR (Drug Utilization Reporting).</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-AS"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-AS">AS</a></td><td>adjudicated as submitted</td><td><div><p>The invoice element was/will be paid exactly as submitted, without financial adjustment(s).</p>
<p>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 &quot;Adjudicated with Adjustment&quot;.</p>
<p>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').</p>
<p>Invoice element can be reversed (nullified).</p>
<p>Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-CONT"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-CONT">CONT</a></td><td>contract</td><td><div><p>Transaction counts and value totals by Contract Identifier.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-DAY"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-DAY">DAY</a></td><td>day</td><td><div><p>Transaction counts and value totals for each calendar day within the date range specified.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-LOC"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-LOC">LOC</a></td><td>location</td><td><div><p>Transaction counts and value totals by service location (e.g clinic).</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-MONTH"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-MONTH">MONTH</a></td><td>month</td><td><div><p>Transaction counts and value totals for each calendar month within the date range specified.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-PERIOD"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-PERIOD">PERIOD</a></td><td>period</td><td><div><p>Transaction counts and value totals for the date range specified.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-PROV"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-PROV">PROV</a></td><td>provider</td><td><div><p>Transaction counts and value totals by Provider Identifier.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-WEEK"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-WEEK">WEEK</a></td><td>week</td><td><div><p>Transaction counts and value totals for each calendar week within the date range specified.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-YEAR"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-YEAR">YEAR</a></td><td>year</td><td><div><p>Transaction counts and value totals for each calendar year within the date range specified.</p>
</div></td></tr><tr><td><a name="R5-v3-ActAdjudicationCode-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-_ActAdjudicationGroupCode"> </a><code>http://terminology.hl7.org/CodeSystem/v3-ActCode</code></td><td>8.0.0</td><td style="white-space:nowrap">  <a href="CodeSystem-v3-ActCode.html#v3-ActCode-_ActAdjudicationGroupCode">_ActAdjudicationGroupCode</a></td><td>ActAdjudicationGroupCode</td><td><div><p>Catagorization of grouping criteria for the associated transactions and/or summary (totals, subtotals).</p>
</div></td></tr></table></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fhir"/>
  </extension>
  <extension url="http://hl7.org/fhir/StructureDefinition/package-source">
    <extension url="packageId">
      <valueId value="hl7.fhir.uv.xver-r5.r4"/>
    </extension>
    <extension url="version">
      <valueString value="0.1.0"/>
    </extension>
    <extension url="uri">
      <valueUri
                value="http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
    <valueInteger value="0">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
      </extension>
    </valueInteger>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="trial-use">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/uv/xver/ValueSet/R5-v3-ActAdjudicationCode-for-R4"/>
  <version value="0.1.0"/>
  <name value="R5V3ActAdjudicationCodeForR4"/>
  <title
         value="Cross-version ValueSet R5.ActAdjudicationCode for use in FHIR R4"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2026-03-17T21:02:03.8104715+00:00"/>
  <publisher value="FHIR Infrastructure"/>
  <contact>
    <name value="FHIR Infrastructure"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fiwg"/>
    </telecom>
  </contact>
  <description
               value="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 value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <purpose
           value="This value set is part of the cross-version definitions generated to enable use of the
value set `http://terminology.hl7.org/ValueSet/v3-ActAdjudicationCode|2.0.0` as defined in FHIR R5
in FHIR R4.

The source value set is bound to the following FHIR R5 elements:
* 

Note that all concepts are included in this cross-version definition because no concepts have compatible representations

Following are the generation technical comments:

FHIR 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 value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <concept>
        <code value="AA"/>
        <display value="adjudicated with adjustments"/>
      </concept>
      <concept>
        <code value="ANF"/>
        <display
                 value="adjudicated with adjustments and no financial impact"/>
      </concept>
      <concept>
        <code value="AR"/>
        <display value="adjudicated as refused"/>
      </concept>
      <concept>
        <code value="AS"/>
        <display value="adjudicated as submitted"/>
      </concept>
      <concept>
        <code value="CONT"/>
        <display value="contract"/>
      </concept>
      <concept>
        <code value="DAY"/>
        <display value="day"/>
      </concept>
      <concept>
        <code value="LOC"/>
        <display value="location"/>
      </concept>
      <concept>
        <code value="MONTH"/>
        <display value="month"/>
      </concept>
      <concept>
        <code value="PERIOD"/>
        <display value="period"/>
      </concept>
      <concept>
        <code value="PROV"/>
        <display value="provider"/>
      </concept>
      <concept>
        <code value="WEEK"/>
        <display value="week"/>
      </concept>
      <concept>
        <code value="YEAR"/>
        <display value="year"/>
      </concept>
      <concept>
        <code value="_ActAdjudicationGroupCode"/>
        <display value="ActAdjudicationGroupCode"/>
      </concept>
    </include>
  </compose>
  <expansion>
    <timestamp value="2026-03-17T21:02:03.8104715+00:00"/>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="AA"/>
      <display value="adjudicated with adjustments"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="ANF"/>
      <display value="adjudicated with adjustments and no financial impact"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="AR"/>
      <display value="adjudicated as refused"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="AS"/>
      <display value="adjudicated as submitted"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="CONT"/>
      <display value="contract"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="DAY"/>
      <display value="day"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="LOC"/>
      <display value="location"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="MONTH"/>
      <display value="month"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="PERIOD"/>
      <display value="period"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="PROV"/>
      <display value="provider"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="WEEK"/>
      <display value="week"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="YEAR"/>
      <display value="year"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="_ActAdjudicationGroupCode"/>
      <display value="ActAdjudicationGroupCode"/>
    </contains>
  </expansion>
</ValueSet>