Da Vinci Payer Data Exchange
2.1.1 - STU 2.1

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

## : PDex Adjudication - JSON Representation

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    {
      "resourceType" : "ValueSet",
      "id" : "PDexAdjudication",
      "text" : {
        "status" : "extensions",
        "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/6.3.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><span title=\"Version is not explicitly stated, which means it is fixed to 1.0.1, the version found through the package references\"> version &#x1F4E6;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/6.3.0/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/6.3.0/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/6.3.0/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/6.3.0/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/6.3.0/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/STU2.1/CodeSystem-C4BBAdjudication.html\"><code>http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication</code></a><span title=\"Version is not explicitly stated, which means it is fixed to 2.1.0, the version found through the package references\"> version &#x1F4E6;2.1.0</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/STU2.1/CodeSystem-C4BBAdjudication.html#C4BBAdjudication-coinsurance\">coinsurance</a></td><td>Coinsurance</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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
          "valueCode" : "fm"
        },
        {
          "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
          "valueCode" : "informative",
          "_valueCode" : {
            "extension" : [
              {
                "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
                "valueCanonical" : "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"
              }
            ]
          }
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication",
      "version" : "2.1.1",
      "name" : "PDexAdjudication",
      "title" : "PDex Adjudication",
      "status" : "active",
      "experimental" : true,
      "date" : "2025-12-18T03:22:36+00:00",
      "publisher" : "HL7 International / Financial Management",
      "contact" : [
        {
          "name" : "HL7 International / Financial Management",
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/fm"
            },
            {
              "system" : "email",
              "value" : "fm@lists.HL7.org"
            }
          ]
        },
        {
          "name" : "Mark Scrimshire (mark.scrimshire@onyxhealth.io)",
          "telecom" : [
            {
              "system" : "email",
              "value" : "mailto:mark.scrimshire@onyxhealth.io"
            }
          ]
        },
        {
          "name" : "HL7 International - Financial Management",
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/fm"
            }
          ]
        }
      ],
      "description" : "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.",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "urn:iso:std:iso:3166",
              "code" : "US",
              "display" : "United States of America"
            }
          ]
        }
      ],
      "copyright" : "This Valueset is not copyrighted.",
      "compose" : {
        "include" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "concept" : [
              {
                "code" : "submitted"
              },
              {
                "code" : "copay"
              },
              {
                "code" : "eligible"
              },
              {
                "code" : "deductible"
              },
              {
                "code" : "benefit"
              }
            ]
          },
          {
            "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
            "concept" : [
              {
                "code" : "coinsurance",
                "display" : "Coinsurance"
              },
              {
                "code" : "noncovered",
                "display" : "Noncovered"
              },
              {
                "code" : "priorpayerpaid",
                "display" : "Prior payer paid"
              },
              {
                "code" : "paidbypatient",
                "display" : "Paid by patient"
              },
              {
                "code" : "paidtopatient",
                "display" : "Paid to patient"
              },
              {
                "code" : "paidtoprovider",
                "display" : "Paid to provider"
              },
              {
                "code" : "memberliability",
                "display" : "Member liability"
              },
              {
                "code" : "discount",
                "display" : "Discount"
              },
              {
                "code" : "drugcost",
                "display" : "Drug cost"
              }
            ]
          }
        ]
      }
    }