Patient Cost Transparency Implementation Guide
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Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

: PCT Financial Type Code System - XML Representation

Page standards status: Trial-use

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="PCTFinancialType"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">allowed<a name="PCTFinancialType-allowed"> </a></td><td>Allowed</td><td>The maximum amount a plan will pay for a covered health care service. May also be called &quot;payment allowance&quot;, or &quot;negotiated rate&quot;.</td></tr><tr><td style="white-space:nowrap">coinsurance<a name="PCTFinancialType-coinsurance"> </a></td><td>Co-Insurance</td><td>The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.</td></tr><tr><td style="white-space:nowrap">copay<a name="PCTFinancialType-copay"> </a></td><td>CoPay</td><td>A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.</td></tr><tr><td style="white-space:nowrap">deductible<a name="PCTFinancialType-deductible"> </a></td><td>Deductible</td><td>The amount the insured individual pays for covered health care services before the insurance plan starts to pay.</td></tr><tr><td style="white-space:nowrap">eligible<a name="PCTFinancialType-eligible"> </a></td><td>Eligible Amount</td><td>Amount of the charge which is considered for adjudication.</td></tr><tr><td style="white-space:nowrap">memberliability<a name="PCTFinancialType-memberliability"> </a></td><td>Member Liability</td><td>The amount of the member's liability.</td></tr><tr><td style="white-space:nowrap">noncovered<a name="PCTFinancialType-noncovered"> </a></td><td>Noncovered</td><td>The portion of the cost of the 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 style="white-space:nowrap">out-of-pocket-maximum<a name="PCTFinancialType-out-of-pocket-maximum"> </a></td><td>Out-of-Pocket Maximum</td><td>The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits.</td></tr><tr><td style="white-space:nowrap">visit<a name="PCTFinancialType-visit"> </a></td><td>Visit</td><td>A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.</td></tr><tr><td style="white-space:nowrap">penalty<a name="PCTFinancialType-penalty"> </a></td><td>Penalty</td><td>Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example.</td></tr></table></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="trial-use">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType"/>
  <version value="1.1.0"/>
  <name value="PCTFinancialType"/>
  <title value="PCT Financial Type Code System"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2023-12-05T22:05:55+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="fmlists@lists.hl7.org"/>
    </telecom>
  </contact>
  <description
               value="Financial Type codes for benefitBalance.financial.type."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
    </coding>
  </jurisdiction>
  <copyright value="This CodeSystem is not copyrighted."/>
  <caseSensitive value="true"/>
  <content value="complete"/>
  <count value="10"/>
  <concept>
    <code value="allowed"/>
    <display value="Allowed"/>
    <definition
                value="The maximum amount a plan will pay for a covered health care service. May also be called &quot;payment allowance&quot;, or &quot;negotiated rate&quot;."/>
  </concept>
  <concept>
    <code value="coinsurance"/>
    <display value="Co-Insurance"/>
    <definition
                value="The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%."/>
  </concept>
  <concept>
    <code value="copay"/>
    <display value="CoPay"/>
    <definition
                value="A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid."/>
  </concept>
  <concept>
    <code value="deductible"/>
    <display value="Deductible"/>
    <definition
                value="The amount the insured individual pays for covered health care services before the insurance plan starts to pay."/>
  </concept>
  <concept>
    <code value="eligible"/>
    <display value="Eligible Amount"/>
    <definition
                value="Amount of the charge which is considered for adjudication."/>
  </concept>
  <concept>
    <code value="memberliability"/>
    <display value="Member Liability"/>
    <definition value="The amount of the member's liability."/>
  </concept>
  <concept>
    <code value="noncovered"/>
    <display value="Noncovered"/>
    <definition
                value="The portion of the cost of the service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract."/>
  </concept>
  <concept>
    <code value="out-of-pocket-maximum"/>
    <display value="Out-of-Pocket Maximum"/>
    <definition
                value="The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits."/>
  </concept>
  <concept>
    <code value="visit"/>
    <display value="Visit"/>
    <definition
                value="A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting."/>
  </concept>
  <concept>
    <code value="penalty"/>
    <display value="Penalty"/>
    <definition
                value="Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example."/>
  </concept>
</CodeSystem>