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 - TTL Representation

Page standards status: Informative

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:ValueSet ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "PDexAdjudication"] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<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 ?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 ?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>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-wg>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "fm"     ]
      ] [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status>     ] ;
    fhir:value [
    a fhir:Code ;
    fhir:v "informative" ;
          ( fhir:extension [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom>         ] ;
    fhir:value [
    a fhir:Canonical ;
    fhir:v "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex>         ]       ] )     ]
      ] ) ; #
      fhir:url [
    fhir:v "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication>
      ] ; #
      fhir:version [ fhir:v "2.1.1"] ; #
      fhir:name [ fhir:v "PDexAdjudication"] ; #
      fhir:title [ fhir:v "PDex Adjudication"] ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:experimental [ fhir:v true] ; #
      fhir:date [ fhir:v "2025-12-18T03:22:36+00:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "HL7 International / Financial Management"] ; #
      fhir:contact ( [
    fhir:name [ fhir:v "HL7 International / Financial Management" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ]     ] [
    fhir:system [ fhir:v "email" ] ;
    fhir:value [ fhir:v "fm@lists.HL7.org" ]     ] )
      ] [
    fhir:name [ fhir:v "Mark Scrimshire (mark.scrimshire@onyxhealth.io)" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "email" ] ;
    fhir:value [ fhir:v "mailto:mark.scrimshire@onyxhealth.io" ]     ] )
      ] [
    fhir:name [ fhir:v "HL7 International - Financial Management" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "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:jurisdiction ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ;
    fhir:l <urn:iso:std:iso:3166>       ] ;
    fhir:code [ fhir:v "US" ] ;
    fhir:display [ fhir:v "United States of America" ]     ] )
      ] ) ; #
      fhir:copyright [ fhir:v "This Valueset is not copyrighted."] ; #
      fhir:compose [
        ( fhir:include [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/adjudication>       ] ;
          ( fhir:concept [
    fhir:code [ fhir:v "submitted" ]       ] [
    fhir:code [ fhir:v "copay" ]       ] [
    fhir:code [ fhir:v "eligible" ]       ] [
    fhir:code [ fhir:v "deductible" ]       ] [
    fhir:code [ fhir:v "benefit" ]       ] )     ] [
    fhir:system [
    fhir:v "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication>       ] ;
          ( fhir:concept [
    fhir:code [ fhir:v "coinsurance" ] ;
    fhir:display [ fhir:v "Coinsurance" ]       ] [
    fhir:code [ fhir:v "noncovered" ] ;
    fhir:display [ fhir:v "Noncovered" ]       ] [
    fhir:code [ fhir:v "priorpayerpaid" ] ;
    fhir:display [ fhir:v "Prior payer paid" ]       ] [
    fhir:code [ fhir:v "paidbypatient" ] ;
    fhir:display [ fhir:v "Paid by patient" ]       ] [
    fhir:code [ fhir:v "paidtopatient" ] ;
    fhir:display [ fhir:v "Paid to patient" ]       ] [
    fhir:code [ fhir:v "paidtoprovider" ] ;
    fhir:display [ fhir:v "Paid to provider" ]       ] [
    fhir:code [ fhir:v "memberliability" ] ;
    fhir:display [ fhir:v "Member liability" ]       ] [
    fhir:code [ fhir:v "discount" ] ;
    fhir:display [ fhir:v "Discount" ]       ] [
    fhir:code [ fhir:v "drugcost" ] ;
    fhir:display [ fhir:v "Drug cost" ]       ] )     ] )
      ] . #