CARIN Consumer Directed Payer Data Exchange
0.1.3 - 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 0.1.3). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

ValueSet: C4BB Adjudication

Summary

Defining URL:http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
Version:0.1.3
Name:C4BBAdjudication"C4BB Adjudication"
Status:Active
Definition:

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

Publisher:HL7 Financial Management Working Group
Copyright:

This Valueset is not copyrighted.

Source Resource:XML / JSON / Turtle

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

  • Include these codes as defined in http://terminology.hl7.org/CodeSystem/adjudication
    CodeDisplay
    submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
    copayCoPayPatient Co-Payment
    eligibleEligible AmountAmount of the change which is considered for adjudication.
    deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
    benefitBenefit AmountAmount payable under the coverage
  • Include these codes as defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
    CodeDisplay
    coinsuranceCoinsuranceThe 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%.
    noncoveredNoncoveredThe 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.
    priorpayerpaidPrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
    paidbypatientPaid by patientThe amount paid by the patient at the point of service.
    paidtopatientPaid to patientpaid to patient
    paidtoproviderPaid to providerThe amount paid to the provider.
    memberliabilityMember liabilityThe amount of the member's liability.
    discountDiscountThe amount of the discount
    drugcostDrug 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

 

Expansion

This value set contains 14 concepts

CodeSystemDisplayDefinition
submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted AmountThe total submitted amount for the claim or group or line item.
copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPayPatient Co-Payment
eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible AmountAmount of the change which is considered for adjudication.
deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductibleAmount deducted from the eligible amount prior to adjudication.
benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit AmountAmount payable under the coverage
coinsurancehttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCoinsuranceThe 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%.
noncoveredhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationNoncoveredThe 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.
priorpayerpaidhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
paidbypatienthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid by patientThe amount paid by the patient at the point of service.
paidtopatienthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid to patientpaid to patient
paidtoproviderhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid to providerThe amount paid to the provider.
memberliabilityhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationMember liabilityThe amount of the member's liability.
discounthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscountThe amount of the discount
drugcosthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDrug 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

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