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 - XML Representation

Page standards status: Informative

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