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 - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:CodeSystem;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "PayerAdjudicationCategoryCS"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.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>"
  ];
  fhir:CodeSystem.url [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/PayerAdjudicationCategoryCS"];
  fhir:CodeSystem.version [ fhir:value "0.3.1"];
  fhir:CodeSystem.name [ fhir:value "PayerAdjudicationCategoryCS"];
  fhir:CodeSystem.title [ fhir:value "Payer Adjudication Category"];
  fhir:CodeSystem.status [ fhir:value "active"];
  fhir:CodeSystem.date [ fhir:value "2020-08-04T02:04:45+00:00"^^xsd:dateTime];
  fhir:CodeSystem.publisher [ fhir:value "HL7 Financial Management Working Group"];
  fhir:CodeSystem.contact [
     fhir:index 0;
     fhir:ContactDetail.name [ fhir:value "HL7 Financial Management Working Group" ];
     fhir:ContactDetail.telecom [
       fhir:index 0;
       fhir:ContactPoint.system [ fhir:value "url" ];
       fhir:ContactPoint.value [ fhir:value "http://www.hl7.org/Special/committees/fm/index.cfm" ]     ], [
       fhir:index 1;
       fhir:ContactPoint.system [ fhir:value "email" ];
       fhir:ContactPoint.value [ fhir:value "fm@lists.HL7.org" ]     ]
  ];
  fhir:CodeSystem.description [ fhir:value "Payer Adjudication Category"];
  fhir:CodeSystem.jurisdiction [
     fhir:index 0;
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "urn:iso:std:iso:3166" ];
       fhir:Coding.code [ fhir:value "US" ]     ]
  ];
  fhir:CodeSystem.content [ fhir:value "complete"];
  fhir:CodeSystem.count [ fhir:value "23"^^xsd:nonNegativeInteger];
  fhir:CodeSystem.concept [
     fhir:index 0;
     fhir:CodeSystem.concept.code [ fhir:value "in-network" ];
     fhir:CodeSystem.concept.display [ fhir:value "In-network" ];
     fhir:CodeSystem.concept.definition [ fhir:value "in-network" ]
  ], [
     fhir:index 1;
     fhir:CodeSystem.concept.code [ fhir:value "out-of-network" ];
     fhir:CodeSystem.concept.display [ fhir:value "Out-of-network" ];
     fhir:CodeSystem.concept.definition [ fhir:value "out-of-network" ]
  ], [
     fhir:index 2;
     fhir:CodeSystem.concept.code [ fhir:value "other" ];
     fhir:CodeSystem.concept.display [ fhir:value "Other" ];
     fhir:CodeSystem.concept.definition [ fhir:value "other" ]
  ], [
     fhir:index 3;
     fhir:CodeSystem.concept.code [ fhir:value "contracted" ];
     fhir:CodeSystem.concept.display [ fhir:value "Contracted" ];
     fhir:CodeSystem.concept.definition [ fhir:value "contracted" ]
  ], [
     fhir:index 4;
     fhir:CodeSystem.concept.code [ fhir:value "non-contracted" ];
     fhir:CodeSystem.concept.display [ fhir:value "Non-contracted" ];
     fhir:CodeSystem.concept.definition [ fhir:value "non-contracted" ]
  ], [
     fhir:index 5;
     fhir:CodeSystem.concept.code [ fhir:value "subscriber" ];
     fhir:CodeSystem.concept.display [ fhir:value "Subscriber" ];
     fhir:CodeSystem.concept.definition [ fhir:value "subscriber" ]
  ], [
     fhir:index 6;
     fhir:CodeSystem.concept.code [ fhir:value "provider" ];
     fhir:CodeSystem.concept.display [ fhir:value "Provider" ];
     fhir:CodeSystem.concept.definition [ fhir:value "provider" ]
  ], [
     fhir:index 7;
     fhir:CodeSystem.concept.code [ fhir:value "paid" ];
     fhir:CodeSystem.concept.display [ fhir:value "Paid" ];
     fhir:CodeSystem.concept.definition [ fhir:value "paid" ]
  ], [
     fhir:index 8;
     fhir:CodeSystem.concept.code [ fhir:value "denied" ];
     fhir:CodeSystem.concept.display [ fhir:value "Denied" ];
     fhir:CodeSystem.concept.definition [ fhir:value "denied" ]
  ], [
     fhir:index 9;
     fhir:CodeSystem.concept.code [ fhir:value "submitted" ];
     fhir:CodeSystem.concept.display [ fhir:value "Submitted" ];
     fhir:CodeSystem.concept.definition [ fhir:value "The total submitted amount for the claim or group or line item." ]
  ], [
     fhir:index 10;
     fhir:CodeSystem.concept.code [ fhir:value "allowed" ];
     fhir:CodeSystem.concept.display [ fhir:value "Allowed" ];
     fhir:CodeSystem.concept.definition [ fhir:value "Allowed" ]
  ], [
     fhir:index 11;
     fhir:CodeSystem.concept.code [ fhir:value "deductible" ];
     fhir:CodeSystem.concept.display [ fhir:value "Deductible" ];
     fhir:CodeSystem.concept.definition [ fhir:value "Amount deducted from the eligible amount prior to adjudication." ]
  ], [
     fhir:index 12;
     fhir:CodeSystem.concept.code [ fhir:value "coinsurance" ];
     fhir:CodeSystem.concept.display [ fhir:value "coinsurance" ];
     fhir:CodeSystem.concept.definition [ fhir:value "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%." ]
  ], [
     fhir:index 13;
     fhir:CodeSystem.concept.code [ fhir:value "copay" ];
     fhir:CodeSystem.concept.display [ fhir:value "copay" ];
     fhir:CodeSystem.concept.definition [ fhir:value "Patient Co-Payment" ]
  ], [
     fhir:index 14;
     fhir:CodeSystem.concept.code [ fhir:value "noncovered" ];
     fhir:CodeSystem.concept.display [ fhir:value "Noncovered" ];
     fhir:CodeSystem.concept.definition [ fhir:value "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." ]
  ], [
     fhir:index 15;
     fhir:CodeSystem.concept.code [ fhir:value "priorpayerpaid" ];
     fhir:CodeSystem.concept.display [ fhir:value "Prior payer paid" ];
     fhir:CodeSystem.concept.definition [ fhir:value "The reduction in the payment amount to reflect the carrier as a secondary payor." ]
  ], [
     fhir:index 16;
     fhir:CodeSystem.concept.code [ fhir:value "payment" ];
     fhir:CodeSystem.concept.display [ fhir:value "Payment" ];
     fhir:CodeSystem.concept.definition [ fhir:value "payment" ]
  ], [
     fhir:index 17;
     fhir:CodeSystem.concept.code [ fhir:value "paidbypatient" ];
     fhir:CodeSystem.concept.display [ fhir:value "Paid by patient" ];
     fhir:CodeSystem.concept.definition [ fhir:value "The amount paid by the patient at the point of service." ]
  ], [
     fhir:index 18;
     fhir:CodeSystem.concept.code [ fhir:value "paidtopatient" ];
     fhir:CodeSystem.concept.display [ fhir:value "Paid to patient" ];
     fhir:CodeSystem.concept.definition [ fhir:value "paid to patient" ]
  ], [
     fhir:index 19;
     fhir:CodeSystem.concept.code [ fhir:value "paidtoprovider" ];
     fhir:CodeSystem.concept.display [ fhir:value "Paid to provider" ];
     fhir:CodeSystem.concept.definition [ fhir:value "The amount paid to the provider." ]
  ], [
     fhir:index 20;
     fhir:CodeSystem.concept.code [ fhir:value "memberliability" ];
     fhir:CodeSystem.concept.display [ fhir:value "Member liability" ];
     fhir:CodeSystem.concept.definition [ fhir:value "The amount of the member's liability." ]
  ], [
     fhir:index 21;
     fhir:CodeSystem.concept.code [ fhir:value "discount" ];
     fhir:CodeSystem.concept.display [ fhir:value "Discount" ];
     fhir:CodeSystem.concept.definition [ fhir:value "The amount of the discount" ]
  ], [
     fhir:index 22;
     fhir:CodeSystem.concept.code [ fhir:value "drugcost" ];
     fhir:CodeSystem.concept.display [ fhir:value "Drug cost" ];
     fhir:CodeSystem.concept.definition [ fhir:value "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" ]
  ].

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.