CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
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CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 2.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

: C4BB Adjudication Value Set - JSON Representation

Active as of 2022-11-28

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{
  "resourceType" : "ValueSet",
  "id" : "C4BBAdjudication",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This value set includes codes based on the following rules:</p><ul><li>Include these codes as defined in <a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html#adjudication-submitted\">submitted</a></td><td>Submitted Amount</td><td>The total submitted amount for the claim or group or line item.</td></tr><tr><td><a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html#adjudication-copay\">copay</a></td><td>CoPay</td><td>Patient Co-Payment</td></tr><tr><td><a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html#adjudication-eligible\">eligible</a></td><td>Eligible Amount</td><td>Amount of the change which is considered for adjudication.</td></tr><tr><td><a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html#adjudication-deductible\">deductible</a></td><td>Deductible</td><td>Amount deducted from the eligible amount prior to adjudication.</td></tr><tr><td><a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html#adjudication-benefit\">benefit</a></td><td>Benefit Amount</td><td>Amount payable under the coverage</td></tr></table></li><li>Include these codes as defined in <a href=\"CodeSystem-C4BBAdjudication.html\"><code>http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-coinsurance\">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><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-noncovered\">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><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-priorpayerpaid\">priorpayerpaid</a></td><td>Prior payer paid</td><td>The reduction in the payment amount to reflect the carrier as a secondary payer.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatient\">paidbypatient</a></td><td>Paid by patient</td><td>The total amount paid by the patient without specifying the source.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatientcash\">paidbypatientcash</a></td><td>Paid by patient - cash</td><td>The amount paid by the patient using cash, check, or other personal account.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatientother\">paidbypatientother</a></td><td>Paid by patient - other</td><td>The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtopatient\">paidtopatient</a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtoprovider\">paidtoprovider</a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-memberliability\">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-drugcost\">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></li></ul></div>"
  },
  "url" : "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication",
  "version" : "2.0.0",
  "name" : "C4BBAdjudication",
  "title" : "C4BB Adjudication Value Set",
  "status" : "active",
  "experimental" : false,
  "date" : "2022-11-28T14:27:00+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"
        },
        {
          "system" : "email",
          "value" : "fm@lists.HL7.org"
        }
      ]
    }
  ],
  "description" : "Describes the various amount fields used when payers receive and adjudicate a claim.  It includes the values \ndefined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "copyright" : "This Valueset is not copyrighted.",
  "compose" : {
    "include" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
        "concept" : [
          {
            "code" : "submitted"
          },
          {
            "code" : "copay"
          },
          {
            "code" : "eligible"
          },
          {
            "code" : "deductible"
          },
          {
            "code" : "benefit"
          }
        ]
      },
      {
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
        "concept" : [
          {
            "code" : "coinsurance",
            "display" : "Coinsurance"
          },
          {
            "code" : "noncovered",
            "display" : "Noncovered"
          },
          {
            "code" : "priorpayerpaid",
            "display" : "Prior payer paid"
          },
          {
            "code" : "paidbypatient",
            "display" : "Paid by patient"
          },
          {
            "code" : "paidbypatientcash",
            "display" : "Paid by patient - cash"
          },
          {
            "code" : "paidbypatientother",
            "display" : "Paid by patient - other"
          },
          {
            "code" : "paidtopatient",
            "display" : "Paid to patient"
          },
          {
            "code" : "paidtoprovider",
            "display" : "Paid to provider"
          },
          {
            "code" : "memberliability",
            "display" : "Member liability"
          },
          {
            "code" : "discount",
            "display" : "Discount"
          },
          {
            "code" : "drugcost",
            "display" : "Drug cost"
          }
        ]
      }
    ]
  }
}