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 https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: Payer Adjudication Category - JSON Representation

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{
  "resourceType" : "CodeSystem",
  "id" : "PayerAdjudicationCategoryCS",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This code system http://hl7.org/fhir/us/carin-bb/CodeSystem/PayerAdjudicationCategoryCS 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\">in-network<a name=\"PayerAdjudicationCategoryCS-in-network\"> </a></td><td>In-network</td><td>in-network</td></tr><tr><td style=\"white-space:nowrap\">out-of-network<a name=\"PayerAdjudicationCategoryCS-out-of-network\"> </a></td><td>Out-of-network</td><td>out-of-network</td></tr><tr><td style=\"white-space:nowrap\">other<a name=\"PayerAdjudicationCategoryCS-other\"> </a></td><td>Other</td><td>other</td></tr><tr><td style=\"white-space:nowrap\">contracted<a name=\"PayerAdjudicationCategoryCS-contracted\"> </a></td><td>Contracted</td><td>contracted</td></tr><tr><td style=\"white-space:nowrap\">non-contracted<a name=\"PayerAdjudicationCategoryCS-non-contracted\"> </a></td><td>Non-contracted</td><td>non-contracted</td></tr><tr><td style=\"white-space:nowrap\">subscriber<a name=\"PayerAdjudicationCategoryCS-subscriber\"> </a></td><td>Subscriber</td><td>subscriber</td></tr><tr><td style=\"white-space:nowrap\">provider<a name=\"PayerAdjudicationCategoryCS-provider\"> </a></td><td>Provider</td><td>provider</td></tr><tr><td style=\"white-space:nowrap\">paid<a name=\"PayerAdjudicationCategoryCS-paid\"> </a></td><td>Paid</td><td>paid</td></tr><tr><td style=\"white-space:nowrap\">denied<a name=\"PayerAdjudicationCategoryCS-denied\"> </a></td><td>Denied</td><td>denied</td></tr><tr><td style=\"white-space:nowrap\">submitted<a name=\"PayerAdjudicationCategoryCS-submitted\"> </a></td><td>Submitted</td><td>The total submitted amount for the claim or group or line item.</td></tr><tr><td style=\"white-space:nowrap\">allowed<a name=\"PayerAdjudicationCategoryCS-allowed\"> </a></td><td>Allowed</td><td>Allowed</td></tr><tr><td style=\"white-space:nowrap\">deductible<a name=\"PayerAdjudicationCategoryCS-deductible\"> </a></td><td>Deductible</td><td>Amount deducted from the eligible amount prior to adjudication.</td></tr><tr><td style=\"white-space:nowrap\">coinsurance<a name=\"PayerAdjudicationCategoryCS-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 style=\"white-space:nowrap\">copay<a name=\"PayerAdjudicationCategoryCS-copay\"> </a></td><td>copay</td><td>Patient Co-Payment</td></tr><tr><td style=\"white-space:nowrap\">noncovered<a name=\"PayerAdjudicationCategoryCS-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 style=\"white-space:nowrap\">priorpayerpaid<a name=\"PayerAdjudicationCategoryCS-priorpayerpaid\"> </a></td><td>Prior payer paid</td><td>The reduction in the payment amount to reflect the carrier as a secondary payor.</td></tr><tr><td style=\"white-space:nowrap\">payment<a name=\"PayerAdjudicationCategoryCS-payment\"> </a></td><td>Payment</td><td>payment</td></tr><tr><td style=\"white-space:nowrap\">paidbypatient<a name=\"PayerAdjudicationCategoryCS-paidbypatient\"> </a></td><td>Paid by patient</td><td>The amount paid by the patient at the point of service.</td></tr><tr><td style=\"white-space:nowrap\">paidtopatient<a name=\"PayerAdjudicationCategoryCS-paidtopatient\"> </a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td style=\"white-space:nowrap\">paidtoprovider<a name=\"PayerAdjudicationCategoryCS-paidtoprovider\"> </a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td style=\"white-space:nowrap\">memberliability<a name=\"PayerAdjudicationCategoryCS-memberliability\"> </a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td style=\"white-space:nowrap\">discount<a name=\"PayerAdjudicationCategoryCS-discount\"> </a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td style=\"white-space:nowrap\">drugcost<a name=\"PayerAdjudicationCategoryCS-drugcost\"> </a></td><td>Drug cost</td><td>Price 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</td></tr></table></div>"
  },
  "url" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/PayerAdjudicationCategoryCS",
  "version" : "0.3.1",
  "name" : "PayerAdjudicationCategoryCS",
  "title" : "Payer Adjudication Category",
  "status" : "active",
  "date" : "2020-08-04T02:04:45+00:00",
  "publisher" : "HL7 Financial Management Working Group",
  "contact" : [
    {
      "name" : "HL7 Financial Management Working Group",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm/index.cfm"
        },
        {
          "system" : "email",
          "value" : "fm@lists.HL7.org"
        }
      ]
    }
  ],
  "description" : "Payer Adjudication Category",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "content" : "complete",
  "count" : 23,
  "concept" : [
    {
      "code" : "in-network",
      "display" : "In-network",
      "definition" : "in-network"
    },
    {
      "code" : "out-of-network",
      "display" : "Out-of-network",
      "definition" : "out-of-network"
    },
    {
      "code" : "other",
      "display" : "Other",
      "definition" : "other"
    },
    {
      "code" : "contracted",
      "display" : "Contracted",
      "definition" : "contracted"
    },
    {
      "code" : "non-contracted",
      "display" : "Non-contracted",
      "definition" : "non-contracted"
    },
    {
      "code" : "subscriber",
      "display" : "Subscriber",
      "definition" : "subscriber"
    },
    {
      "code" : "provider",
      "display" : "Provider",
      "definition" : "provider"
    },
    {
      "code" : "paid",
      "display" : "Paid",
      "definition" : "paid"
    },
    {
      "code" : "denied",
      "display" : "Denied",
      "definition" : "denied"
    },
    {
      "code" : "submitted",
      "display" : "Submitted",
      "definition" : "The total submitted amount for the claim or group or line item."
    },
    {
      "code" : "allowed",
      "display" : "Allowed",
      "definition" : "Allowed"
    },
    {
      "code" : "deductible",
      "display" : "Deductible",
      "definition" : "Amount deducted from the eligible amount prior to adjudication."
    },
    {
      "code" : "coinsurance",
      "display" : "coinsurance",
      "definition" : "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%."
    },
    {
      "code" : "copay",
      "display" : "copay",
      "definition" : "Patient Co-Payment"
    },
    {
      "code" : "noncovered",
      "display" : "Noncovered",
      "definition" : "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."
    },
    {
      "code" : "priorpayerpaid",
      "display" : "Prior payer paid",
      "definition" : "The reduction in the payment amount to reflect the carrier as a secondary payor."
    },
    {
      "code" : "payment",
      "display" : "Payment",
      "definition" : "payment"
    },
    {
      "code" : "paidbypatient",
      "display" : "Paid by patient",
      "definition" : "The amount paid by the patient at the point of service."
    },
    {
      "code" : "paidtopatient",
      "display" : "Paid to patient",
      "definition" : "paid to patient"
    },
    {
      "code" : "paidtoprovider",
      "display" : "Paid to provider",
      "definition" : "The amount paid to the provider."
    },
    {
      "code" : "memberliability",
      "display" : "Member liability",
      "definition" : "The amount of the member's liability."
    },
    {
      "code" : "discount",
      "display" : "Discount",
      "definition" : "The amount of the discount"
    },
    {
      "code" : "drugcost",
      "display" : "Drug cost",
      "definition" : "Price 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"
    }
  ]
}