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 2.0.0-ballot 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

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: PCT Adjudication Value Set - JSON Representation

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{
  "resourceType" : "ValueSet",
  "id" : "PCTAdjudication",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><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/5.3.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><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/5.3.0/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/5.3.0/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/5.3.0/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/5.3.0/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/5.3.0/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=\"CodeSystem-PCTAdjudication.html\"><code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication</code></a><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=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-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=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-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=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-memberliability\">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href=\"CodeSystem-PCTAdjudication.html#PCTAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr></table></li></ul></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "fm"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication",
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:oid:2.16.840.1.113883.4.642.40.4.48.6"
    }
  ],
  "version" : "2.0.0-ballot",
  "name" : "PCTAdjudication",
  "title" : "PCT Adjudication Value Set",
  "status" : "active",
  "experimental" : false,
  "date" : "2024-04-08T16:35:46+00:00",
  "publisher" : "HL7 International / Financial Management",
  "contact" : [
    {
      "name" : "HL7 International / Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        },
        {
          "system" : "email",
          "value" : "fmlists@lists.hl7.org"
        }
      ]
    }
  ],
  "description" : "Describes the various amount fields used when payers receive and adjudicate a claim.  It includes the values \ndefined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "copyright" : "This Valueset is not copyrighted.",
  "compose" : {
    "include" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
        "concept" : [
          {
            "code" : "submitted"
          },
          {
            "code" : "copay"
          },
          {
            "code" : "eligible"
          },
          {
            "code" : "deductible"
          },
          {
            "code" : "benefit"
          }
        ]
      },
      {
        "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
        "concept" : [
          {
            "code" : "coinsurance",
            "display" : "Coinsurance"
          },
          {
            "code" : "noncovered",
            "display" : "Noncovered"
          },
          {
            "code" : "memberliability",
            "display" : "Member liability"
          },
          {
            "code" : "discount",
            "display" : "Discount"
          }
        ]
      }
    ]
  }
}