Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot
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
| Page standards status: Trial-use |
<ValueSet xmlns="http://hl7.org/fhir">
<id value="PCTAdjudication"/>
<text>
<status value="extensions"/>
<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>
</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/ValueSet/PCTAdjudication"/>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:oid:2.16.840.1.113883.4.642.40.4.48.6"/>
</identifier>
<version value="2.0.0-ballot"/>
<name value="PCTAdjudication"/>
<title value="PCT Adjudication Value Set"/>
<status value="active"/>
<experimental value="false"/>
<date value="2024-04-08T16:35:46+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="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"/>
</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/davinci-pct/CodeSystem/PCTAdjudication"/>
<concept>
<code value="coinsurance"/>
<display value="Coinsurance"/>
</concept>
<concept>
<code value="noncovered"/>
<display value="Noncovered"/>
</concept>
<concept>
<code value="memberliability"/>
<display value="Member liability"/>
</concept>
<concept>
<code value="discount"/>
<display value="Discount"/>
</concept>
</include>
</compose>
</ValueSet>
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-08
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