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 Financial Type Code System - XML Representation

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

Raw xml | Download

    <CodeSystem xmlns="http://hl7.org/fhir">
      <id value="PCTFinancialType"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem PCTFinancialType</b></p><a name="PCTFinancialType"> </a><a name="hcPCTFinancialType"> </a><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">allowed<a name="PCTFinancialType-allowed"> </a></td><td>Allowed</td><td>The maximum amount a plan will pay for a covered health care service. May also be called &quot;payment allowance&quot;, or &quot;negotiated rate&quot;.</td></tr><tr><td style="white-space:nowrap">coinsurance<a name="PCTFinancialType-coinsurance"> </a></td><td>Co-Insurance</td><td>The 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%.</td></tr><tr><td style="white-space:nowrap">copay<a name="PCTFinancialType-copay"> </a></td><td>CoPay</td><td>A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.</td></tr><tr><td style="white-space:nowrap">deductible<a name="PCTFinancialType-deductible"> </a></td><td>Deductible</td><td>The amount the insured individual pays for covered health care services before the insurance plan starts to pay.</td></tr><tr><td style="white-space:nowrap">eligible<a name="PCTFinancialType-eligible"> </a></td><td>Eligible Amount</td><td>Amount of the charge which is considered for adjudication.</td></tr><tr><td style="white-space:nowrap">memberliability<a name="PCTFinancialType-memberliability"> </a></td><td>Member Liability</td><td>The amount of the member's liability.</td></tr><tr><td style="white-space:nowrap">noncovered<a name="PCTFinancialType-noncovered"> </a></td><td>Noncovered</td><td>The 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.</td></tr><tr><td style="white-space:nowrap">out-of-pocket-maximum<a name="PCTFinancialType-out-of-pocket-maximum"> </a></td><td>Out-of-Pocket Maximum</td><td>The 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.</td></tr><tr><td style="white-space:nowrap">visit<a name="PCTFinancialType-visit"> </a></td><td>Visit</td><td>A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.</td></tr><tr><td style="white-space:nowrap">penalty<a name="PCTFinancialType-penalty"> </a></td><td>Penalty</td><td>Benefit 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.</td></tr></table></div>
      </text>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
        <valueCode value="fm"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
        <valueInteger value="2">
          <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>
        </valueInteger>
      </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/CodeSystem/PCTFinancialType"/>
      <identifier>
        <system value="urn:ietf:rfc:3986"/>
        <value value="urn:oid:2.16.840.1.113883.4.642.40.4.16.8"/>
      </identifier>
      <version value="2.0.1"/>
      <name value="PCTFinancialType"/>
      <title value="PCT Financial Type Code System"/>
      <status value="active"/>
      <experimental value="false"/>
      <date value="2026-03-26T13:47:00+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="Financial Type codes for benefitBalance.financial.type. This CodeSystem is currently defined by this IG, but is anticipated to be temporary. The concepts within are expected to be moved in a future version to a more central terminology specification such as THO, which will result in a code system url change and possibly modified codes and definitions."/>
      <jurisdiction>
        <coding>
          <system value="urn:iso:std:iso:3166"/>
          <code value="US"/>
        </coding>
      </jurisdiction>
      <copyright value="This CodeSystem is not copyrighted."/>
      <caseSensitive value="true"/>
      <content value="complete"/>
      <count value="10"/>
      <concept>
        <code value="allowed"/>
        <display value="Allowed"/>
        <definition
                    value="The maximum amount a plan will pay for a covered health care service. May also be called &quot;payment allowance&quot;, or &quot;negotiated rate&quot;."/>
      </concept>
      <concept>
        <code value="coinsurance"/>
        <display value="Co-Insurance"/>
        <definition
                    value="The 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%."/>
      </concept>
      <concept>
        <code value="copay"/>
        <display value="CoPay"/>
        <definition
                    value="A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid."/>
      </concept>
      <concept>
        <code value="deductible"/>
        <display value="Deductible"/>
        <definition
                    value="The amount the insured individual pays for covered health care services before the insurance plan starts to pay."/>
      </concept>
      <concept>
        <code value="eligible"/>
        <display value="Eligible Amount"/>
        <definition
                    value="Amount of the charge which is considered for adjudication."/>
      </concept>
      <concept>
        <code value="memberliability"/>
        <display value="Member Liability"/>
        <definition value="The amount of the member's liability."/>
      </concept>
      <concept>
        <code value="noncovered"/>
        <display value="Noncovered"/>
        <definition
                    value="The 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."/>
      </concept>
      <concept>
        <code value="out-of-pocket-maximum"/>
        <display value="Out-of-Pocket Maximum"/>
        <definition
                    value="The 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."/>
      </concept>
      <concept>
        <code value="visit"/>
        <display value="Visit"/>
        <definition
                    value="A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting."/>
      </concept>
      <concept>
        <code value="penalty"/>
        <display value="Penalty"/>
        <definition
                    value="Benefit 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."/>
      </concept>
    </CodeSystem>