Patient Cost Transparency Implementation Guide
2.0.0 - STU 2 - Draft 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 Total Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: PCTTotal
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.48.34

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 Network Status.

References

Changes since version 1.1.0:

  • New Content

    • Logical Definition (CLD)

    This value set includes codes based on the following rules:

     

    Expansion

    This value set contains 12 concepts

    CodeSystemDisplayDefinition
      submittedhttp://terminology.hl7.org/CodeSystem/adjudicationSubmitted AmountThe total submitted amount for the claim or group or line item.
      copayhttp://terminology.hl7.org/CodeSystem/adjudicationCoPayPatient Co-Payment
      eligiblehttp://terminology.hl7.org/CodeSystem/adjudicationEligible AmountAmount of the change which is considered for adjudication.
      deductiblehttp://terminology.hl7.org/CodeSystem/adjudicationDeductibleAmount deducted from the eligible amount prior to adjudication.
      benefithttp://terminology.hl7.org/CodeSystem/adjudicationBenefit AmountAmount payable under the coverage
      coinsurancehttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCoinsuranceThe 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/PCTAdjudicationNoncoveredThe 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 liabilityThe amount of the member's liability.
      discounthttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationDiscountThe amount of the discount
      innetworkhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCSIn NetworkIndicates an in network status in relation to a patient's coverage
      outofnetworkhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCSOut Of NetworkIndicates a not in network status in relation to a patient's coverage
      negotiatedhttp://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCSNegotiated Service or ProductIndicates a special negotiated status in relation to a patient's coverage

    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