Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
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
| Page standards status: Trial-use |
{
"resourceType" : "ValueSet",
"id" : "PCTAdjudication",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet PCTAdjudication</b></p><a name=\"PCTAdjudication\"> </a><a name=\"hcPCTAdjudication\"> </a><a name=\"PCTAdjudication-en-US\"> </a><p>This value set includes codes based on the following rules:</p><ul><li>Include these codes as defined in <a href=\"http://terminology.hl7.org/6.1.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"http://terminology.hl7.org/6.1.0/CodeSystem-adjudication.html#adjudication-submitted\">submitted</a></td><td style=\"color: #cccccc\">Submitted Amount</td><td>The total submitted amount for the claim or group or line item.</td></tr><tr><td><a href=\"http://terminology.hl7.org/6.1.0/CodeSystem-adjudication.html#adjudication-copay\">copay</a></td><td style=\"color: #cccccc\">CoPay</td><td>Patient Co-Payment</td></tr><tr><td><a href=\"http://terminology.hl7.org/6.1.0/CodeSystem-adjudication.html#adjudication-eligible\">eligible</a></td><td style=\"color: #cccccc\">Eligible Amount</td><td>Amount of the change which is considered for adjudication.</td></tr><tr><td><a href=\"http://terminology.hl7.org/6.1.0/CodeSystem-adjudication.html#adjudication-deductible\">deductible</a></td><td style=\"color: #cccccc\">Deductible</td><td>Amount deducted from the eligible amount prior to adjudication.</td></tr><tr><td><a href=\"http://terminology.hl7.org/6.1.0/CodeSystem-adjudication.html#adjudication-benefit\">benefit</a></td><td style=\"color: #cccccc\">Benefit Amount</td><td>Amount payable under the coverage</td></tr></table></li><li>Include these codes as defined in <a href=\"CodeSystem-PCTAdjudication.html\"><code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-coinsurance\">coinsurance</a></td><td>Coinsurance</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><a href=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-noncovered\">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><a href=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-memberliability\">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr></table></li></ul></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode" : "trial-use",
"_valueCode" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication",
"identifier" : [
{
"system" : "urn:ietf:rfc:3986",
"value" : "urn:oid:2.16.840.1.113883.4.642.40.4.48.6"
}
],
"version" : "2.0.0-ballot",
"name" : "PCTAdjudication",
"title" : "PCT Adjudication Value Set",
"status" : "active",
"experimental" : false,
"date" : "2024-11-20T18:01:40+00:00",
"publisher" : "HL7 International / Financial Management",
"contact" : [
{
"name" : "HL7 International / Financial Management",
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/fm"
},
{
"system" : "email",
"value" : "fmlists@lists.hl7.org"
}
]
}
],
"description" : "Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values \ndefined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"copyright" : "This Valueset is not copyrighted.",
"compose" : {
"include" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"concept" : [
{
"code" : "submitted"
},
{
"code" : "copay"
},
{
"code" : "eligible"
},
{
"code" : "deductible"
},
{
"code" : "benefit"
}
]
},
{
"system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
"concept" : [
{
"code" : "coinsurance",
"display" : "Coinsurance"
},
{
"code" : "noncovered",
"display" : "Noncovered"
},
{
"code" : "memberliability",
"display" : "Member liability"
},
{
"code" : "discount",
"display" : "Discount"
}
]
}
]
}
}
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-11-20
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