Patient Cost Transparency Implementation Guide
2.0.0-draft - STU 2 - Draft United States of America flag

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-draft 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

ValueSet: PCT Adjudication Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication Version: 2.0.0-draft
Standards status: Trial-use Computable Name: PCTAdjudication
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.48.6

Copyright/Legal: This Valueset is not copyrighted.

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

References

Changes since version 1.1.0:

  • No changes
  • Logical Definition (CLD)

    Generated Narrative: ValueSet PCTAdjudication

    This value set includes codes based on the following rules:

    • Include these codes as defined in http://terminology.hl7.org/CodeSystem/adjudication
      CodeDisplayDefinition
      submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
      copayCoPayPatient Co-Payment
      eligibleEligible AmountAmount of the change which is considered for adjudication.
      deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
      benefitBenefit AmountAmount payable under the coverage
    • Include these codes as defined in http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
      CodeDisplayDefinition
      coinsurance Coinsurance 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%.
      noncovered Noncovered 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.
      memberliability Member liability The amount of the member's liability.
      discount Discount The amount of the discount

     

    Expansion

    Generated Narrative: ValueSet

    This value set contains 9 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.

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

    Amount payable under the coverage

      coinsurancehttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCoinsurance

    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%.

      noncoveredhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationNoncovered

    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.

      memberliabilityhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationMember liability

    The amount of the member's liability.

      discounthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationDiscount

    The amount of the discount


    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