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

## ValueSet: PDex Adjudication (Experimental)

Official URL: http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication | Version: 2.1.1
Standards status: Informative | Computable Name: PDexAdjudication
Copyright/Legal: This Valueset is not copyrighted.

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

References

- Included into PDexAdjudicationCategoryDiscriminator
- PDex Prior Authorization

### Logical Definition (CLD)

This value set includes codes based on the following rules:

- Include these codes as defined in `http://terminology.hl7.org/CodeSystem/adjudication` version 📦1.0.1

  Code | Display | Definition
  submitted | Submitted Amount | The total submitted amount for the claim or group or line item.
  copay | CoPay | Patient Co-Payment
  eligible | Eligible Amount | Amount of the change which is considered for adjudication.
  deductible | Deductible | Amount deducted from the eligible amount prior to adjudication.
  benefit | Benefit Amount | Amount payable under the coverage

- Include these codes as defined in `http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` version 📦2.1.0

  Code | Display | Definition
  coinsurance | 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 | 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 | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payer.
  paidbypatient | Paid by patient | The total amount paid by the patient without specifying the source.
  paidtopatient | Paid to patient | paid to patient
  paidtoprovider | Paid to provider | The amount paid to the provider.
  memberliability | Member liability | The amount of the member's liability.
  discount | Discount | The amount of the discount
  drugcost | 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

### Expansion

Expansion performed internally based on:

- codesystem C4BB Adjudication Code System v2.1.0 (CodeSystem)
- codesystem Adjudication Value Codes v1.0.1 (CodeSystem)

This value set contains 14 concepts

System | Code | Display (en) | Definition | JSON | XML
`http://terminology.hl7.org/CodeSystem/adjudication` | submitted | Submitted Amount | The total submitted amount for the claim or group or line item. |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | copay | CoPay | Patient Co-Payment |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | eligible | Eligible Amount | Amount of the change which is considered for adjudication. |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | deductible | Deductible | Amount deducted from the eligible amount prior to adjudication. |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | benefit | Benefit Amount | Amount payable under the coverage |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | coinsurance | 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%. |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | noncovered | 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. |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | priorpayerpaid | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payer. |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | paidbypatient | Paid by patient | The total amount paid by the patient without specifying the source. |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | paidtopatient | Paid to patient | paid to patient |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | paidtoprovider | Paid to provider | The amount paid to the provider. |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | memberliability | Member liability | The amount of the member's liability. |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | discount | Discount | The amount of the discount |  |
`http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication` | drugcost | 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 |  |

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