CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1

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 1.0.0). 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

Summary

Defining URL:http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
Version:1.0.0
Name:C4BBAdjudicationCategoryDiscriminator
Title:C4BB Adjudication Category Discriminator
Status:Active as of 2020-11-23T16:49:10+00:00
Definition:

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

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:

 

Expansion

This value set contains 17 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
allowedunitshttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorallowed unitsdefines the adjudication slice to define allowed units
inoutnetworkhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorin or Out of Networkdefines the adjudication and item.adjudication slice to indicate whether a claim was adjudicatd in or out of network
denialreasonhttp://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminatorDenial Reasondefines the adjudication slice to identify the denial reason

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