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 https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions
: PCT Financial Type Code System - TTL Representation
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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:CodeSystem ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "PCTFinancialType"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType</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\">allowed<a name=\"PCTFinancialType-allowed\"> </a></td><td>Allowed</td><td>The maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".</td></tr><tr><td style=\"white-space:nowrap\">coinsurance<a name=\"PCTFinancialType-coinsurance\"> </a></td><td>Co-Insurance</td><td>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%.</td></tr><tr><td style=\"white-space:nowrap\">copay<a name=\"PCTFinancialType-copay\"> </a></td><td>CoPay</td><td>A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.</td></tr><tr><td style=\"white-space:nowrap\">deductible<a name=\"PCTFinancialType-deductible\"> </a></td><td>Deductible</td><td>The amount the insured individual pays for covered health care services before the insurance plan starts to pay.</td></tr><tr><td style=\"white-space:nowrap\">eligible<a name=\"PCTFinancialType-eligible\"> </a></td><td>Eligible Amount</td><td>Amount of the charge which is considered for adjudication.</td></tr><tr><td style=\"white-space:nowrap\">memberliability<a name=\"PCTFinancialType-memberliability\"> </a></td><td>Member Liability</td><td>The amount of the member's liability.</td></tr><tr><td style=\"white-space:nowrap\">noncovered<a name=\"PCTFinancialType-noncovered\"> </a></td><td>Noncovered</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">out-of-pocket-maximum<a name=\"PCTFinancialType-out-of-pocket-maximum\"> </a></td><td>Out-of-Pocket Maximum</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">visit<a name=\"PCTFinancialType-visit\"> </a></td><td>Visit</td><td>A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.</td></tr><tr><td style=\"white-space:nowrap\">penalty<a name=\"PCTFinancialType-penalty\"> </a></td><td>Penalty</td><td>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.</td></tr></table></div>"
] ; #
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ;
fhir:value [ fhir:v "fm" ]
] [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ] ;
fhir:value [
fhir:v "trial-use" ;
( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ] ;
fhir:value [
fhir:v "http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct> ] ] ) ]
] ) ; #
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"^^xsd:anyURI] ; #
fhir:identifier ( [
fhir:system [ fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ] ;
fhir:value [ fhir:v "urn:oid:2.16.840.1.113883.4.642.40.4.16.8" ]
] ) ; #
fhir:version [ fhir:v "2.0.0-ballot"] ; #
fhir:name [ fhir:v "PCTFinancialType"] ; #
fhir:title [ fhir:v "PCT Financial Type Code System"] ; #
fhir:status [ fhir:v "active"] ; #
fhir:experimental [ fhir:v "false"^^xsd:boolean] ; #
fhir:date [ fhir:v "2024-04-08T16:35:46+00:00"^^xsd:dateTime] ; #
fhir:publisher [ fhir:v "HL7 International / Financial Management"] ; #
fhir:contact ( [
fhir:name [ fhir:v "HL7 International / Financial Management" ] ;
( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ] ] [
fhir:system [ fhir:v "email" ] ;
fhir:value [ fhir:v "fmlists@lists.hl7.org" ] ] )
] ) ; #
fhir:description [ fhir:v "Financial Type codes for benefitBalance.financial.type. 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."] ; #
fhir:jurisdiction ( [
( fhir:coding [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "US" ] ] )
] ) ; #
fhir:copyright [ fhir:v "This CodeSystem is not copyrighted."] ; #
fhir:caseSensitive [ fhir:v "true"^^xsd:boolean] ; #
fhir:content [ fhir:v "complete"] ; #
fhir:count [ fhir:v "10"^^xsd:nonNegativeInteger] ; #
fhir:concept ( [
fhir:code [ fhir:v "allowed" ] ;
fhir:display [ fhir:v "Allowed" ] ;
fhir:definition [ fhir:v "The maximum amount a plan will pay for a covered health care service. May also be called \"payment allowance\", or \"negotiated rate\"." ]
] [
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Co-Insurance" ] ;
fhir:definition [ fhir:v "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%." ]
] [
fhir:code [ fhir:v "copay" ] ;
fhir:display [ fhir:v "CoPay" ] ;
fhir:definition [ fhir:v "A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid." ]
] [
fhir:code [ fhir:v "deductible" ] ;
fhir:display [ fhir:v "Deductible" ] ;
fhir:definition [ fhir:v "The amount the insured individual pays for covered health care services before the insurance plan starts to pay." ]
] [
fhir:code [ fhir:v "eligible" ] ;
fhir:display [ fhir:v "Eligible Amount" ] ;
fhir:definition [ fhir:v "Amount of the charge which is considered for adjudication." ]
] [
fhir:code [ fhir:v "memberliability" ] ;
fhir:display [ fhir:v "Member Liability" ] ;
fhir:definition [ fhir:v "The amount of the member's liability." ]
] [
fhir:code [ fhir:v "noncovered" ] ;
fhir:display [ fhir:v "Noncovered" ] ;
fhir:definition [ fhir:v "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." ]
] [
fhir:code [ fhir:v "out-of-pocket-maximum" ] ;
fhir:display [ fhir:v "Out-of-Pocket Maximum" ] ;
fhir:definition [ fhir:v "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." ]
] [
fhir:code [ fhir:v "visit" ] ;
fhir:display [ fhir:v "Visit" ] ;
fhir:definition [ fhir:v "A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting." ]
] [
fhir:code [ fhir:v "penalty" ] ;
fhir:display [ fhir:v "Penalty" ] ;
fhir:definition [ fhir:v "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." ]
] ) . #
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