Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot US

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v2.0.0-ballot: STU 2 Ballot) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

ValueSet: PCT GFE Item Adjudication Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS Version: 2.0.0-ballot
Standards status: Trial-use Computable Name: PCTAdjudicationCategoryVS
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.48.7

Copyright/Legal: This Valueset is not copyrighted.

Value Set containing codes for the type of adjudication information provided.

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

 

Expansion

This value set contains 14 concepts.

CodeSystemDisplayDefinition
  submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted Amount

The total submitted amount for the claim or group or line item.

  copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPay

Patient Co-Payment

  eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible Amount

Amount of the change which is considered for adjudication.

  deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductible

Amount deducted from the eligible amount prior to adjudication.

  unallocdeducthttp://terminology.hl7.org/CodeSystem/adjudicationUnallocated Deductible

The amount of deductible which could not allocated to other line items.

  eligpercenthttp://terminology.hl7.org/CodeSystem/adjudicationEligible %

Eligible Percentage.

  taxhttp://terminology.hl7.org/CodeSystem/adjudicationTax

The amount of tax.

  benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit Amount

Amount payable under the coverage

  billingnetworkstatushttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCSBilling Network Status

Indicates the Billing Provider network status in relation to the patient's coverage.

  renderingnetworkstatushttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCSRendering Network Status

Indicates the Rendering Provider network status in relation to the patient's coverage.

  benefitpaymentstatushttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCSBenefit Payment Status

Indicates the in network or out of network payment status of the claim.

  adjustmentreasonhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCSAdjustment Reason

Defines the adjudication slice to identify the adjustment reason

  medicalmanagementhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCSMedical Management

Defines the adjudication slice to identify medical management

  memberliabilityhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCSMember Liability

Defines the adjudication slice to identify member liability

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code