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 2.1.1 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
Official URL: http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator | Version: 2.1.1 | |||
Standards status: Informative | Computable Name: PDexAdjudicationCategoryDiscriminator | |||
Copyright/Legal: This Valueset is not copyrighted. |
Used as the discriminator for adjudication.category and item.adjudication.category for the PDex Prior Authorization.
References
Generated Narrative: ValueSet PDexAdjudicationCategoryDiscriminator
This value set includes codes based on the following rules:
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
Generated Narrative: ValueSet
Expansion based on:
This value set contains 23 concepts
Code | System | Display | Definition |
submitted | http://terminology.hl7.org/CodeSystem/adjudication | Submitted Amount | The total submitted amount for the claim or group or line item. |
copay | http://terminology.hl7.org/CodeSystem/adjudication | CoPay | Patient Co-Payment |
eligible | http://terminology.hl7.org/CodeSystem/adjudication | Eligible Amount | Amount of the change which is considered for adjudication. |
deductible | http://terminology.hl7.org/CodeSystem/adjudication | Deductible | Amount deducted from the eligible amount prior to adjudication. |
benefit | http://terminology.hl7.org/CodeSystem/adjudication | Benefit Amount | Amount payable under the coverage |
coinsurance | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Coinsurance | 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 | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | 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 | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payer. |
paidbypatient | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid by patient | The total amount paid by the patient without specifying the source. |
paidtopatient | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid to patient | paid to patient |
paidtoprovider | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid to provider | The amount paid to the provider. |
memberliability | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Member liability | The amount of the member's liability. |
discount | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Discount | The amount of the discount |
drugcost | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | 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 |
innetwork | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus | In Network | Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider |
outofnetwork | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus | Out Of Network | Indicates the claim or claim line was paid out of network. This does not indicate the contracting status of the provider |
other | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus | Other | Indicates other network status or when a network does not apply |
paidbypatientcash | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid by patient - cash | The amount paid by the patient using cash, check, or other personal account. |
paidbypatientother | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid by patient - other | The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account. |
paidbypatienthealthaccount | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid by patient - health account | The amount paid by the patient using another method like HSA, HRA, FSA or other type of health account. |
allowedunits | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | allowed units | defines the adjudication slice to define allowed units |
consumedunits | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | consumed units | defines the adjudication slice to define consumed units |
denialreason | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | Denial Reason | defines 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 |
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 |