Patient Cost Transparency Implementation Guide
1.1.0 - STU 1 United States of America flag

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

ValueSet: PCT Adjudication Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication Version: 1.1.0
Standards status: Trial-use Computable Name: PCTAdjudication

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

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
    CodeDisplayDefinition
    submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
    copayCoPayPatient Co-Payment
    eligibleEligible AmountAmount of the change which is considered for adjudication.
    deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
    benefitBenefit AmountAmount payable under the coverage
  • Include these codes as defined in http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    CodeDisplayDefinition
    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%.
    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.
    memberliabilityMember liabilityThe amount of the member's liability.
    discountDiscountThe amount of the discount

 

Expansion

This value set contains 9 concepts

CodeSystemDisplayDefinition
  submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted Amount

The total submitted amount for the claim or group or line item.

  copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPay

Patient Co-Payment

  eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible Amount

Amount of the change which is considered for adjudication.

  deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductible

Amount deducted from the eligible amount prior to adjudication.

  benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit Amount

Amount payable under the coverage

  coinsurancehttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCoinsurance

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%.

  noncoveredhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationNoncovered

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.

  memberliabilityhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationMember liability

The amount of the member's liability.

  discounthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationDiscount

The amount of the discount


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