CARIN Consumer Directed Payer Data Exchange
0.3.1 - STU1

CARIN Consumer Directed Payer Data Exchange, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.3.1). This version is based on the current content of and changes regularly. See the Directory of published versions

CodeSystem: Payer Adjudication Category


Defining URL:
Title:Payer Adjudication Category
Content:All the concepts defined by the code system are included in the code system resource

Payer Adjudication Category

Publisher:HL7 Financial Management Working Group
Content Mode:Complete
Source Resource:XML / JSON / Turtle

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

This code system defines the following codes:

in-network In-networkin-network
out-of-network Out-of-networkout-of-network
other Otherother
contracted Contractedcontracted
non-contracted Non-contractednon-contracted
subscriber Subscribersubscriber
provider Providerprovider
paid Paidpaid
denied Denieddenied
submitted SubmittedThe total submitted amount for the claim or group or line item.
allowed AllowedAllowed
deductible DeductibleAmount deducted from the eligible amount prior to adjudication.
coinsurance coinsuranceThe 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%.
copay copayPatient Co-Payment
noncovered NoncoveredThe 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.
priorpayerpaid Prior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
payment Paymentpayment
paidbypatient Paid by patientThe amount paid by the patient at the point of service.
paidtopatient Paid to patientpaid to patient
paidtoprovider Paid to providerThe amount paid to the provider.
memberliability Member liabilityThe amount of the member's liability.
discount DiscountThe amount of the discount
drugcost Drug costPrice paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration