{
  "resourceType" : "ValueSet",
  "id" : "C4BBAdjudication",
  "language" : "en",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet C4BBAdjudication</b></p><a name=\"C4BBAdjudication\"> </a><a name=\"hcC4BBAdjudication\"> </a><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/7.1.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><span title=\"Version is explicitly stated to be 1.0.1\"> version &#x1F4CD;1.0.1</span><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/7.1.0/CodeSystem-adjudication.html#adjudication-submitted\">submitted</a></td><td style=\"color: #cccccc\">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/7.1.0/CodeSystem-adjudication.html#adjudication-copay\">copay</a></td><td style=\"color: #cccccc\">CoPay</td><td>Patient Co-Payment</td></tr><tr><td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-adjudication.html#adjudication-eligible\">eligible</a></td><td style=\"color: #cccccc\">Eligible Amount</td><td>Amount of the change which is considered for adjudication.</td></tr><tr><td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-adjudication.html#adjudication-deductible\">deductible</a></td><td style=\"color: #cccccc\">Deductible</td><td>Amount deducted from the eligible amount prior to adjudication.</td></tr><tr><td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-adjudication.html#adjudication-benefit\">benefit</a></td><td style=\"color: #cccccc\">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><span title=\"Version is not explicitly stated, which means it is fixed to the version provided in this specification\"> version &#x1F4E6;2.2.0</span><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>Co-insurance</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-paidbypatienthealthaccount\">paidbypatienthealthaccount</a></td><td>Paid by patient - health account</td><td>The amount paid by the patient using another method like HSA, HRA, FSA or other type of 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>"
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "fm"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 2,
    "_valueInteger" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/carin-bb/ImplementationGuide/hl7.fhir.us.carin-bb"
      }]
    }
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/carin-bb/ImplementationGuide/hl7.fhir.us.carin-bb"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication",
  "version" : "2.2.0",
  "name" : "C4BBAdjudication",
  "title" : "C4BB Adjudication Value Set",
  "status" : "active",
  "experimental" : false,
  "date" : "2026-03-24T21:31:02+00:00",
  "publisher" : "HL7 International / Financial Management",
  "contact" : [{
    "name" : "HL7 International / Financial Management",
    "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",
      "version" : "1.0.1",
      "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" : "Co-insurance"
      },
      {
        "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" : "paidbypatienthealthaccount",
        "display" : "Paid by patient - health account"
      },
      {
        "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"
      }]
    }]
  }
}