Patient Cost Transparency Implementation Guide
2.0.0 - STU 2 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 2.0.0 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 Financial Type Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: PCTFinancialTypeVS
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.48.17

Financial Type codes for benefitBalance.financial.type.

References

Changes since version 1.1.0:

  • No changes

    • Logical Definition (CLD)

     

    Expansion

    Expansion performed internally based on codesystem PCT Financial Type Code System v2.0.0 (CodeSystem)

    This value set contains 10 concepts

    SystemCodeDisplay (en)DefinitionJSONXML
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  allowedAllowedThe maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  coinsuranceCo-InsuranceThe 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%.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  copayCoPayA fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  deductibleDeductibleThe amount the insured individual pays for covered health care services before the insurance plan starts to pay.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  eligibleEligible AmountAmount of the charge which is considered for adjudication.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  memberliabilityMember LiabilityThe amount of the member's liability.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  noncoveredNoncoveredThe 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.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  out-of-pocket-maximumOut-of-Pocket MaximumThe 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.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  visitVisitA medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  penaltyPenaltyBenefit 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.

    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