The total submitted amount for the claim or group or line item.

Patient Co-Payment

Amount of the change which is considered for adjudication.

Amount deducted from the eligible amount prior to adjudication.

Amount payable under the coverage

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%.

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.

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

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

paid to patient

The amount paid to the provider.

The amount of the member's liability.

The amount of the discount

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

Indicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider

Indicates the claim or claim line was paid out of network. This does not indicate the contracting status of the provider

Indicates other network status or when a network does not apply

defines the adjudication slice to define allowed units

defines the adjudication slice to define consumed units

defines the adjudication slice to identify the denial reason