CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: C4BB Adjudication Code System - XML Representation

Page standards status: Trial-use

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="C4BBAdjudication"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem C4BBAdjudication</b></p><a name="C4BBAdjudication"> </a><a name="hcC4BBAdjudication"> </a><a name="C4BBAdjudication-en-US"> </a><p>This case-sensitive code system <code>http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">coinsurance<a name="C4BBAdjudication-coinsurance"> </a></td><td>Co-insurance</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 style="white-space:nowrap">noncovered<a name="C4BBAdjudication-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 style="white-space:nowrap">priorpayerpaid<a name="C4BBAdjudication-priorpayerpaid"> </a></td><td>Prior payer paid</td><td>The reduction in the payment amount to reflect the carrier as a secondary payer.</td></tr><tr><td style="white-space:nowrap">paidbypatient<a name="C4BBAdjudication-paidbypatient"> </a></td><td>Paid by patient</td><td>The total amount paid by the patient without specifying the source.</td></tr><tr><td style="white-space:nowrap">paidbypatientcash<a name="C4BBAdjudication-paidbypatientcash"> </a></td><td>Paid by patient - cash</td><td>The amount paid by the patient using cash, check, or other personal account.</td></tr><tr><td style="white-space:nowrap">paidbypatientother<a name="C4BBAdjudication-paidbypatientother"> </a></td><td>Paid by patient - other</td><td>The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.</td></tr><tr><td style="white-space:nowrap">paidbypatienthealthaccount<a name="C4BBAdjudication-paidbypatienthealthaccount"> </a></td><td>Paid by patient - health account</td><td>The amount paid by the patient using another method like HSA, HRA, FSA or other type of health account.</td></tr><tr><td style="white-space:nowrap">paidtoprovider<a name="C4BBAdjudication-paidtoprovider"> </a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td style="white-space:nowrap">paidtopatient<a name="C4BBAdjudication-paidtopatient"> </a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td style="white-space:nowrap">memberliability<a name="C4BBAdjudication-memberliability"> </a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td style="white-space:nowrap">discount<a name="C4BBAdjudication-discount"> </a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td style="white-space:nowrap">drugcost<a name="C4BBAdjudication-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></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fm"/>
  </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/us/carin-bb/ImplementationGuide/hl7.fhir.us.carin-bb"/>
      </extension>
    </valueCode>
  </extension>
  <url value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"/>
  <version value="2.1.0"/>
  <name value="C4BBAdjudication"/>
  <title value="C4BB Adjudication Code System"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2024-12-18T23:56:31+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>
  <description
               value="Describes the various amount fields used when payers receive and adjudicate a claim.  It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

This is a code system defined locally by the CARIN BlueButton IG. As this IG matures, it is expected that this CodeSystem will be migrated to THO (terminology.hl7.org). The current CodeSystem url should be considered temporary and subject to change in a future version."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
    </coding>
  </jurisdiction>
  <copyright value="This CodeSystem is not copyrighted."/>
  <caseSensitive value="true"/>
  <content value="complete"/>
  <count value="12"/>
  <concept>
    <code value="coinsurance"/>
    <display value="Co-insurance"/>
    <definition
                value="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%."/>
  </concept>
  <concept>
    <code value="noncovered"/>
    <display value="Noncovered"/>
    <definition
                value="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."/>
  </concept>
  <concept>
    <code value="priorpayerpaid"/>
    <display value="Prior payer paid"/>
    <definition
                value="The reduction in the payment amount to reflect the carrier as a secondary payer."/>
  </concept>
  <concept>
    <code value="paidbypatient"/>
    <display value="Paid by patient"/>
    <definition
                value="The total amount paid by the patient without specifying the source."/>
  </concept>
  <concept>
    <code value="paidbypatientcash"/>
    <display value="Paid by patient - cash"/>
    <definition
                value="The amount paid by the patient using cash, check, or other personal account."/>
  </concept>
  <concept>
    <code value="paidbypatientother"/>
    <display value="Paid by patient - other"/>
    <definition
                value="The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account."/>
  </concept>
  <concept>
    <code value="paidbypatienthealthaccount"/>
    <display value="Paid by patient - health account"/>
    <definition
                value="The amount paid by the patient using another method like HSA, HRA, FSA or other type of health account."/>
  </concept>
  <concept>
    <code value="paidtoprovider"/>
    <display value="Paid to provider"/>
    <definition value="The amount paid to the provider."/>
  </concept>
  <concept>
    <code value="paidtopatient"/>
    <display value="Paid to patient"/>
    <definition value="paid to patient"/>
  </concept>
  <concept>
    <code value="memberliability"/>
    <display value="Member liability"/>
    <definition value="The amount of the member's liability."/>
  </concept>
  <concept>
    <code value="discount"/>
    <display value="Discount"/>
    <definition value="The amount of the discount"/>
  </concept>
  <concept>
    <code value="drugcost"/>
    <display value="Drug cost"/>
    <definition
                value="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"/>
  </concept>
</CodeSystem>