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

ValueSet: PDex Adjudication (Experimental)

Official URL: http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication Version: 2.1.0
Active as of 2024-03-01 Computable Name: PDexAdjudication

Copyright/Legal: This Valueset is not copyrighted.

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the PDex Adjudication CodeSystem.

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

  • Include these codes as defined in http://terminology.hl7.org/CodeSystem/adjudication
    CodeDisplayDefinition
    submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
    copayCoPayPatient Co-Payment
    eligibleEligible AmountAmount of the change which is considered for adjudication.
    deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
    benefitBenefit AmountAmount payable under the coverage
  • Include these codes as defined in http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS
    CodeDisplayDefinition
    coinsuranceCoinsuranceThe 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%.
    noncoveredNoncoveredThe 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.
    priorpayerpaidPrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
    paidbypatientPaid by patientThe amount paid by the patient at the point of service.
    paidtopatientPaid to patientpaid to patient
    paidtoproviderPaid to providerThe amount paid to the provider.
    memberliabilityMember liabilityThe amount of the member's liability.
    discountDiscountThe amount of the discount
    drugcostDrug 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

 

Expansion

This value set contains 14 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/davinci-pdex/CodeSystem/PDexAdjudicationCSCoinsurance

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/davinci-pdex/CodeSystem/PDexAdjudicationCSNoncovered

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/davinci-pdex/CodeSystem/PDexAdjudicationCSPrior payer paid

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

  paidbypatienthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPaid by patient

The amount paid by the patient at the point of service.

  paidtopatienthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPaid to patient

paid to patient

  paidtoproviderhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSPaid to provider

The amount paid to the provider.

  memberliabilityhttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSMember liability

The amount of the member's liability.

  discounthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSDiscount

The amount of the discount

  drugcosthttp://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCSDrug 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


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