Da Vinci Payer Data Exchange
2.1.1 - STU 2.1 United States of America flag

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 Category Discriminator (Experimental)

Official URL: http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator Version: 2.1.1
Standards status: Informative Computable Name: PDexAdjudicationCategoryDiscriminator

Copyright/Legal: This Valueset is not copyrighted.

Used as the discriminator for adjudication.category and item.adjudication.category for the PDex Prior Authorization.

References

Logical Definition (CLD)

This value set includes codes based on the following rules:

 

Expansion

This value set contains 23 concepts

SystemCodeDisplay (en)DefinitionJSONXML
http://terminology.hl7.org/CodeSystem/adjudication  submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
http://terminology.hl7.org/CodeSystem/adjudication  copayCoPayPatient Co-Payment
http://terminology.hl7.org/CodeSystem/adjudication  eligibleEligible AmountAmount of the change which is considered for adjudication.
http://terminology.hl7.org/CodeSystem/adjudication  deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
http://terminology.hl7.org/CodeSystem/adjudication  benefitBenefit AmountAmount payable under the coverage
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  coinsuranceCoinsuranceThe 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  noncoveredNoncoveredThe 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  priorpayerpaidPrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payer.
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  paidbypatientPaid by patientThe total amount paid by the patient without specifying the source.
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  paidtopatientPaid to patientpaid to patient
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  paidtoproviderPaid to providerThe amount paid to the provider.
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  memberliabilityMember liabilityThe amount of the member's liability.
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  discountDiscountThe amount of the discount
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  drugcostDrug costPrice 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
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus  innetworkIn NetworkIndicates the claim or claim line was paid in network. This does not indicate the contracting status of the provider
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus  outofnetworkOut Of NetworkIndicates the claim or claim line was paid out of network. This does not indicate the contracting status of the provider
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexPayerAdjudicationStatus  otherOtherIndicates other network status or when a network does not apply
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  paidbypatientcashPaid by patient - cashThe amount paid by the patient using cash, check, or other personal account.
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  paidbypatientotherPaid by patient - otherThe amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication  paidbypatienthealthaccountPaid by patient - health accountThe amount paid by the patient using another method like HSA, HRA, FSA or other type of health account.
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator  allowedunitsallowed unitsdefines the adjudication slice to define allowed units
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator  consumedunitsconsumed unitsdefines the adjudication slice to define consumed units
http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator  denialreasonDenial Reasondefines the adjudication slice to identify the denial reason

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