HL7 Terminology (THO)
2.1.35 - Continuous Process Integration (ci build) [last update: UP-239]

HL7 Terminology (THO), published by HL7 International - Vocabulary Work Group. This is not an authorized publication; it is the continuous build for version 2.1.35). This version is based on the current content of https://github.com/HL7/UTG/ and changes regularly. See the Directory of published versions

ValueSet: ActAdjudicationCode

Summary

Defining URL:http://terminology.hl7.org/ValueSet/v3-ActAdjudicationCode
Version:2.0.0
Name:ActAdjudicationCode
Status:Active as of 2014-03-26
Definition:

Includes coded responses that will occur as a result of the adjudication of an electronic invoice at a summary level and provides guidance on interpretation of the referenced adjudication results.

OID:2.16.840.1.113883.1.11.17616 (for OID based terminology systems)
Source Resource:XML / JSON / Turtle

References

This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

Logical Definition (CLD)

This value set includes codes based on the following rules:

This value set excludes codes based on the following rules:

 

Expansion

This value set contains 12 concepts

Expansion based on ActCode v6.0.0 (CodeSystem)

All codes in this table are from the system http://terminology.hl7.org/CodeSystem/v3-ActCode

CodeDisplayDefinition
_ActAdjudicationGroupCodeActAdjudicationGroupCodeCatagorization of grouping criteria for the associated transactions and/or summary (totals, subtotals).
CONTcontractTransaction counts and value totals by Contract Identifier.
DAYdayTransaction counts and value totals for each calendar day within the date range specified.
LOClocationTransaction counts and value totals by service location (e.g clinic).
MONTHmonthTransaction counts and value totals for each calendar month within the date range specified.
PERIODperiodTransaction counts and value totals for the date range specified.
PROVproviderTransaction counts and value totals by Provider Identifier.
WEEKweekTransaction counts and value totals for each calendar week within the date range specified.
YEARyearTransaction counts and value totals for each calendar year within the date range specified.
AAadjudicated with adjustmentsThe invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges). Also includes the concept 'Adjudicate as zero' and items not covered under a particular Policy. Invoice element can be reversed (nullified). Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).
ANFadjudicated with adjustments and no financial impactThe invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges) without changing the amount. Invoice element can be reversed (nullified). Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).
ARadjudicated as refusedThe invoice element has passed through the adjudication process but payment is refused due to one or more reasons. Includes items such as patient not covered, or invoice element is not constructed according to payer rules (e.g. 'invoice submitted too late'). If one invoice element line item in the invoice element structure is rejected, the remaining line items may not be adjudicated and the complete group is treated as rejected. A refused invoice element can be forwarded to the next payer (for Coordination of Benefits) or modified and resubmitted to refusing payer. Invoice element cannot be reversed (nullified) as there is nothing to reverse. Recommend that the invoice element is not saved for DUR (Drug Utilization Reporting).
ASadjudicated as submittedThe invoice element was/will be paid exactly as submitted, without financial adjustment(s). If the dollar amount stays the same, but the billing codes have been amended or financial adjustments have been applied through the adjudication process, the invoice element is treated as "Adjudicated with Adjustment". If information items are included in the adjudication results that do not affect the monetary amounts paid, then this is still Adjudicated as Submitted (e.g. 'reached Plan Maximum on this Claim'). Invoice element can be reversed (nullified). Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

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
Source 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

History

DateActionCustodianAuthorComment
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26