Da Vinci Payer Data Exchange
2.1.0 - STU2 United States of America flag

Da Vinci Payer Data Exchange, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

CodeSystem: PDex Adjudication Codes

Official URL: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS Version: 2.1.0
Standards status: Trial-use Computable Name: PDexAdjudicationCS

Copyright/Legal: This CodeSystem is not copyrighted.

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

This Code system is referenced in the content logical definition of the following value sets:

This case-insensitive code system http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS defines the following codes:

CodeDisplayDefinition
coinsurance Co-insurance 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%.
noncovered Noncovered 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.
priorpayerpaid Prior payer paid The reduction in the payment amount to reflect the carrier as a secondary payor.
paidbypatient Paid by patient The amount paid by the patient at the point of service.
paidtoprovider Paid to provider The amount paid to the provider.
paidtopatient Paid to patient paid to patient
memberliability Member liability The amount of the member's liability.
discount Discount The amount of the discount
drugcost Drug 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