Patient Cost Transparency Implementation Guide
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Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of and changes regularly. See the Directory of published versions

CodeSystem: PCT Financial Type Code System

Official URL: Version: 2.0.0-ballot
Standards status: Trial-use Computable Name: PCTFinancialType
Other Identifiers: OID:2.16.840.1.113883.4.642.

Copyright/Legal: This CodeSystem is not copyrighted.

Financial Type codes for This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions.

This Code system is referenced in the content logical definition of the following value sets:

Generated Narrative: CodeSystem PCTFinancialType

This case-sensitive code system defines the following codes:

allowed Allowed The maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".
coinsurance Co-Insurance The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.
copay CoPay A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.
deductible Deductible The amount the insured individual pays for covered health care services before the insurance plan starts to pay.
eligible Eligible Amount Amount of the charge which is considered for adjudication.
memberliability Member Liability The amount of the member's liability.
noncovered Noncovered The portion of the cost of the service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
out-of-pocket-maximum Out-of-Pocket Maximum The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits.
visit Visit A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.
penalty Penalty Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example.