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 - XML Representation

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="PayerAdjudicationCategoryCS"/>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <url
       value="http://hl7.org/fhir/us/carin-bb/CodeSystem/PayerAdjudicationCategoryCS"/>
  <version value="0.3.1"/>
  <name value="PayerAdjudicationCategoryCS"/>
  <title value="Payer Adjudication Category"/>
  <status value="active"/>
  <date value="2020-08-04T02:04:45+00:00"/>
  <publisher value="HL7 Financial Management Working Group"/>
  <contact>
    <name value="HL7 Financial Management Working Group"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm/index.cfm"/>
    </telecom>
    <telecom>
      <system value="email"/>
      <value value="fm@lists.HL7.org"/>
    </telecom>
  </contact>
  <description value="Payer Adjudication Category"/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
    </coding>
  </jurisdiction>
  <content value="complete"/>
  <count value="23"/>
  <concept>
    <code value="in-network"/>
    <display value="In-network"/>
    <definition value="in-network"/>
  </concept>
  <concept>
    <code value="out-of-network"/>
    <display value="Out-of-network"/>
    <definition value="out-of-network"/>
  </concept>
  <concept>
    <code value="other"/>
    <display value="Other"/>
    <definition value="other"/>
  </concept>
  <concept>
    <code value="contracted"/>
    <display value="Contracted"/>
    <definition value="contracted"/>
  </concept>
  <concept>
    <code value="non-contracted"/>
    <display value="Non-contracted"/>
    <definition value="non-contracted"/>
  </concept>
  <concept>
    <code value="subscriber"/>
    <display value="Subscriber"/>
    <definition value="subscriber"/>
  </concept>
  <concept>
    <code value="provider"/>
    <display value="Provider"/>
    <definition value="provider"/>
  </concept>
  <concept>
    <code value="paid"/>
    <display value="Paid"/>
    <definition value="paid"/>
  </concept>
  <concept>
    <code value="denied"/>
    <display value="Denied"/>
    <definition value="denied"/>
  </concept>
  <concept>
    <code value="submitted"/>
    <display value="Submitted"/>
    <definition
                value="The total submitted amount for the claim or group or line item."/>
  </concept>
  <concept>
    <code value="allowed"/>
    <display value="Allowed"/>
    <definition value="Allowed"/>
  </concept>
  <concept>
    <code value="deductible"/>
    <display value="Deductible"/>
    <definition
                value="Amount deducted from the eligible amount prior to adjudication."/>
  </concept>
  <concept>
    <code value="coinsurance"/>
    <display value="coinsurance"/>
    <definition
                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%."/>
  </concept>
  <concept>
    <code value="copay"/>
    <display value="copay"/>
    <definition value="Patient Co-Payment"/>
  </concept>
  <concept>
    <code value="noncovered"/>
    <display value="Noncovered"/>
    <definition
                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."/>
  </concept>
  <concept>
    <code value="priorpayerpaid"/>
    <display value="Prior payer paid"/>
    <definition
                value="The reduction in the payment amount to reflect the carrier as a secondary payor."/>
  </concept>
  <concept>
    <code value="payment"/>
    <display value="Payment"/>
    <definition value="payment"/>
  </concept>
  <concept>
    <code value="paidbypatient"/>
    <display value="Paid by patient"/>
    <definition value="The amount paid by the patient at the point of service."/>
  </concept>
  <concept>
    <code value="paidtopatient"/>
    <display value="Paid to patient"/>
    <definition value="paid to patient"/>
  </concept>
  <concept>
    <code value="paidtoprovider"/>
    <display value="Paid to provider"/>
    <definition value="The amount paid to the provider."/>
  </concept>
  <concept>
    <code value="memberliability"/>
    <display value="Member liability"/>
    <definition value="The amount of the member&#39;s liability."/>
  </concept>
  <concept>
    <code value="discount"/>
    <display value="Discount"/>
    <definition value="The amount of the discount"/>
  </concept>
  <concept>
    <code value="drugcost"/>
    <display value="Drug cost"/>
    <definition
                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"/>
  </concept>
</CodeSystem>