Patient Cost Transparency Implementation Guide
2.0.1 - STU 2

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 2.0.1 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

## : PCT Adjudication Value Set - JSON Representation

Page standards status: Trial-use | Maturity Level: 2

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    {
      "resourceType" : "ValueSet",
      "id" : "PCTAdjudicationVS",
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet PCTAdjudicationVS</b></p><a name=\"PCTAdjudicationVS\"> </a><a name=\"hcPCTAdjudicationVS\"> </a><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/6.5.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><span title=\"Version is explicitly stated to be 1.0.1\"> version &#x1F4CD;1.0.1</span><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/6.5.0/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/6.5.0/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/6.5.0/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/6.5.0/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/6.5.0/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><span title=\"Version is not explicitly stated, which means it is fixed to the version provided in this specification\"> version &#x1F4E6;2.0.1</span><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 style=\"color: #cccccc\">Co-insurance</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 style=\"color: #cccccc\">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 style=\"color: #cccccc\">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 style=\"color: #cccccc\">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-fmm",
          "valueInteger" : 2,
          "_valueInteger" : {
            "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/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/PCTAdjudicationVS",
      "identifier" : [
        {
          "system" : "urn:ietf:rfc:3986",
          "value" : "urn:oid:2.16.840.1.113883.4.642.40.4.48.40"
        }
      ],
      "version" : "2.0.1",
      "name" : "PCTAdjudicationVS",
      "title" : "PCT Adjudication Value Set",
      "status" : "active",
      "experimental" : false,
      "date" : "2026-03-26T13:47:00+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",
            "version" : "1.0.1",
            "concept" : [
              {
                "code" : "submitted"
              },
              {
                "code" : "copay"
              },
              {
                "code" : "eligible"
              },
              {
                "code" : "deductible"
              },
              {
                "code" : "benefit"
              }
            ]
          },
          {
            "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
            "concept" : [
              {
                "code" : "coinsurance"
              },
              {
                "code" : "noncovered"
              },
              {
                "code" : "memberliability"
              },
              {
                "code" : "discount"
              }
            ]
          }
        ]
      }
    }