Da Vinci Payer Data Exchange
2.2.0 - STU 2.2
Da Vinci Payer Data Exchange
2.2.0 - STU 2.2
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 2.2.0 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
| Page standards status: Informative |
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
<http://hl7.org/fhir/ValueSet/PDexAdjudication> a fhir:ValueSet ;
fhir:nodeRole fhir:treeRoot ;
fhir:Resource.id [ fhir:value "PDexAdjudication"] ;
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "extensions" ] ;
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet PDexAdjudication</b></p><a name=\"PDexAdjudication\"> </a><a name=\"hcPDexAdjudication\"> </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/7.2.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><span title=\"Version is explicitly stated to be 1.0.1\"> version ?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/7.2.0/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/7.2.0/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/7.2.0/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/7.2.0/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/7.2.0/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/CodeSystem-C4BBAdjudication.html\"><code>http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication</code></a><span title=\"Version is explicitly stated to be 2.2.0\"> version ?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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtopatient\">paidtopatient</a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td><a href=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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=\"http://hl7.org/fhir/us/carin-bb/STU2.2/CodeSystem-C4BBAdjudication.html#C4BBAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td><a href=\"http://hl7.org/fhir/us/carin-bb/STU2.2/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>"
] ;
fhir:DomainResource.extension [
fhir:index 0 ;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg" ] ;
fhir:Extension.valueCode [ fhir:value "fm" ]
], [
fhir:index 1 ;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status" ] ;
fhir:Extension.valueCode [
fhir:value "informative" ;
fhir:Element.extension [
fhir:index 0 ;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom" ] ;
fhir:Extension.valueCanonical [
fhir:value "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex" ;
fhir:link <http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex>
]
]
]
] ;
fhir:ValueSet.url [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication"] ;
fhir:ValueSet.version [ fhir:value "2.2.0"] ;
fhir:ValueSet.name [ fhir:value "PDexAdjudication"] ;
fhir:ValueSet.title [ fhir:value "PDex Adjudication"] ;
fhir:ValueSet.status [ fhir:value "active"] ;
fhir:ValueSet.experimental [ fhir:value "true"^^xsd:boolean] ;
fhir:ValueSet.date [ fhir:value "2026-06-29T15:03:38+00:00"^^xsd:dateTime] ;
fhir:ValueSet.publisher [ fhir:value "HL7 International / Financial Management"] ;
fhir:ValueSet.contact [
fhir:index 0 ;
fhir:ContactDetail.name [ fhir:value "HL7 International / Financial Management" ] ;
fhir:ContactDetail.telecom [
fhir:index 0 ;
fhir:ContactPoint.system [ fhir:value "url" ] ;
fhir:ContactPoint.value [ fhir:value "http://www.hl7.org/Special/committees/fm" ]
], [
fhir:index 1 ;
fhir:ContactPoint.system [ fhir:value "email" ] ;
fhir:ContactPoint.value [ fhir:value "fm@lists.HL7.org" ]
]
], [
fhir:index 1 ;
fhir:ContactDetail.name [ fhir:value "Mark Scrimshire (mark.scrimshire@onyxhealth.io)" ] ;
fhir:ContactDetail.telecom [
fhir:index 0 ;
fhir:ContactPoint.system [ fhir:value "email" ] ;
fhir:ContactPoint.value [ fhir:value "mailto:mark.scrimshire@onyxhealth.io" ]
]
], [
fhir:index 2 ;
fhir:ContactDetail.name [ fhir:value "HL7 International - Financial Management" ] ;
fhir:ContactDetail.telecom [
fhir:index 0 ;
fhir:ContactPoint.system [ fhir:value "url" ] ;
fhir:ContactPoint.value [ fhir:value "http://www.hl7.org/Special/committees/fm" ]
]
] ;
fhir:ValueSet.description [ fhir:value "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."] ;
fhir:ValueSet.jurisdiction [
fhir:index 0 ;
fhir:CodeableConcept.coding [
fhir:index 0 ;
fhir:Coding.system [ fhir:value "urn:iso:std:iso:3166" ] ;
fhir:Coding.code [ fhir:value "US" ] ;
fhir:Coding.display [ fhir:value "United States of America" ]
]
] ;
fhir:ValueSet.copyright [ fhir:value "This Valueset is not copyrighted."] ;
fhir:ValueSet.compose [
fhir:ValueSet.compose.include [
fhir:index 0 ;
fhir:ValueSet.compose.include.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ;
fhir:ValueSet.compose.include.version [ fhir:value "1.0.1" ] ;
fhir:ValueSet.compose.include.concept [
fhir:index 0 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "submitted" ]
], [
fhir:index 1 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "copay" ]
], [
fhir:index 2 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "eligible" ]
], [
fhir:index 3 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "deductible" ]
], [
fhir:index 4 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "benefit" ]
]
], [
fhir:index 1 ;
fhir:ValueSet.compose.include.system [ fhir:value "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication" ] ;
fhir:ValueSet.compose.include.version [ fhir:value "2.2.0" ] ;
fhir:ValueSet.compose.include.concept [
fhir:index 0 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "coinsurance" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Co-insurance" ]
], [
fhir:index 1 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "noncovered" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Noncovered" ]
], [
fhir:index 2 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "priorpayerpaid" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Prior payer paid" ]
], [
fhir:index 3 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "paidbypatient" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Paid by patient" ]
], [
fhir:index 4 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "paidtopatient" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Paid to patient" ]
], [
fhir:index 5 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "paidtoprovider" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Paid to provider" ]
], [
fhir:index 6 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "memberliability" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Member liability" ]
], [
fhir:index 7 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "discount" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Discount" ]
], [
fhir:index 8 ;
fhir:ValueSet.compose.include.concept.code [ fhir:value "drugcost" ] ;
fhir:ValueSet.compose.include.concept.display [ fhir:value "Drug cost" ]
]
]
] .
# - ontology header ------------------------------------------------------------
<http://hl7.org/fhir/ValueSet/PDexAdjudication.ttl> a owl:Ontology ;
owl:imports fhir:fhir.ttl ;
owl:versionIRI <http://build.fhir.org/ValueSet/PDexAdjudication.ttl> .
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pdex#2.2.0 based on FHIR 4.0.1. Generated 2026-06-29
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