CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), 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 - 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:ValueSet ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "C4BBAdjudication"] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir: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>"
] ; #
fhir:url [ fhir:v "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication"^^xsd:anyURI] ; #
fhir:version [ fhir:v "2.0.0"] ; #
fhir:name [ fhir:v "C4BBAdjudication"] ; #
fhir:title [ fhir:v "C4BB Adjudication Value Set"] ; #
fhir:status [ fhir:v "active"] ; #
fhir:experimental [ fhir:v "false"^^xsd:boolean] ; #
fhir:date [ fhir:v "2023-08-02T12:35:50+00:00"^^xsd:dateTime] ; #
fhir:publisher [ fhir:v "HL7 Financial Management Working Group"] ; #
fhir:contact ( [
fhir:name [ fhir:v "HL7 Financial Management Working Group" ] ;
( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ] ] [
fhir:system [ fhir:v "email" ] ;
fhir:value [ fhir:v "fm@lists.HL7.org" ] ] )
] ) ; #
fhir:description [ fhir:v "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."] ; #
fhir:jurisdiction ( [
( fhir:coding [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "US" ] ] )
] ) ; #
fhir:copyright [ fhir:v "This Valueset is not copyrighted."] ; #
fhir:compose [
( fhir:include [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
( fhir:concept [
fhir:code [ fhir:v "submitted" ] ] [
fhir:code [ fhir:v "copay" ] ] [
fhir:code [ fhir:v "eligible" ] ] [
fhir:code [ fhir:v "deductible" ] ] [
fhir:code [ fhir:v "benefit" ] ] ) ] [
fhir:system [ fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ] ;
( fhir:concept [
fhir:code [ fhir:v "coinsurance" ] ;
fhir:display [ fhir:v "Coinsurance" ] ] [
fhir:code [ fhir:v "noncovered" ] ;
fhir:display [ fhir:v "Noncovered" ] ] [
fhir:code [ fhir:v "priorpayerpaid" ] ;
fhir:display [ fhir:v "Prior payer paid" ] ] [
fhir:code [ fhir:v "paidbypatient" ] ;
fhir:display [ fhir:v "Paid by patient" ] ] [
fhir:code [ fhir:v "paidbypatientcash" ] ;
fhir:display [ fhir:v "Paid by patient - cash" ] ] [
fhir:code [ fhir:v "paidbypatientother" ] ;
fhir:display [ fhir:v "Paid by patient - other" ] ] [
fhir:code [ fhir:v "paidtopatient" ] ;
fhir:display [ fhir:v "Paid to patient" ] ] [
fhir:code [ fhir:v "paidtoprovider" ] ;
fhir:display [ fhir:v "Paid to provider" ] ] [
fhir:code [ fhir:v "memberliability" ] ;
fhir:display [ fhir:v "Member liability" ] ] [
fhir:code [ fhir:v "discount" ] ;
fhir:display [ fhir:v "Discount" ] ] [
fhir:code [ fhir:v "drugcost" ] ;
fhir:display [ fhir:v "Drug cost" ] ] ) ] )
] . #
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