CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 United States of America flag

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

ValueSet: C4BB Adjudication Category Discriminator Value Set

Official URL: http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator Version: 2.0.0
Active as of 2022-11-28 Computable Name: C4BBAdjudicationCategoryDiscriminator

Copyright/Legal: This Valueset is not copyrighted.

Used as the discriminator for adjudication.category and item.adjudication.category for the CARIN IG for Blue Button®

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

 

Expansion

This value set contains 22 concepts

CodeSystemDisplayDefinition
  submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted Amount

The total submitted amount for the claim or group or line item.

  copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPay

Patient Co-Payment

  eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible Amount

Amount of the change which is considered for adjudication.

  deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductible

Amount deducted from the eligible amount prior to adjudication.

  benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit Amount

Amount payable under the coverage

  coinsurancehttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCoinsurance

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%.

  noncoveredhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationNoncovered

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.

  priorpayerpaidhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPrior payer paid

The reduction in the payment amount to reflect the carrier as a secondary payer.

  paidbypatienthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid by patient

The total amount paid by the patient without specifying the source.

  paidbypatientcashhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid by patient - cash

The amount paid by the patient using cash, check, or other personal account.

  paidbypatientotherhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid by patient - other

The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.

  paidtopatienthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid to patient

paid to patient

  paidtoproviderhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationPaid to provider

The amount paid to the provider.

  memberliabilityhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationMember liability

The amount of the member's liability.

  discounthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscount

The amount of the discount

  drugcosthttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDrug cost

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

  allowedunitshttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorallowed units

defines the adjudication slice to define allowed units

  adjustmentreasonhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorAdjustment Reason

Defines the adjudication slice to identify the adjustment reason

  rejectreasonhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorReject Reason

Defines the adjudication slice to identify the reject reason

  billingnetworkstatushttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorBilling Network Status

Indicates the Billing Provider network status in relation to a patient's coverage as of the effective date of service or admission.

  renderingnetworkstatushttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorRendering Network Status

Indicates the Rendering Provider network status in relation to a patient's coverage as of the effective date of service or admission.

  benefitpaymentstatushttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorBenefit Payment Status

Indicates the network payment status in relation to a patient's coverage as of the effective date of service or admission.


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
System 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