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

## ValueSet: PCT Total Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal | Version: 2.0.1
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

- PCT Advanced EOB
- PCT Advanced EOB
- PCT Advanced EOB Summary
- PCT Advanced EOB Summary

Changes since version 1.1.0:

- New Content

### Logical Definition (CLD)

This value set includes codes based on the following rules:

- Import all the codes that are contained in PCT Adjudication Value Set
- Include these codes as defined in `http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS` version 📦2.0.1

  Code | Display | Definition
  innetwork | In Network | Indicates an in network status in relation to a patient's coverage
  outofnetwork | Out Of Network | Indicates a not in network status in relation to a patient's coverage
  negotiated | Negotiated Service or Product | Indicates a special negotiated status in relation to a patient's coverage

### Expansion

Expansion performed internally based on:

- codesystem PCT Adjudication Code System v2.0.1 (CodeSystem)
- codesystem PCT Network Status v2.0.1 (CodeSystem)
- codesystem Adjudication Value Codes v1.0.1 (CodeSystem)
- valueset PCT Adjudication Value Set v2.0.1 (ValueSet)

This value set contains 12 concepts

System | Code | Display (en) | Definition | JSON | XML
`http://terminology.hl7.org/CodeSystem/adjudication` | submitted | Submitted Amount | The total submitted amount for the claim or group or line item. |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | copay | CoPay | Patient Co-Payment |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | eligible | Eligible Amount | Amount of the change which is considered for adjudication. |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | deductible | Deductible | Amount deducted from the eligible amount prior to adjudication. |  |
`http://terminology.hl7.org/CodeSystem/adjudication` | benefit | Benefit Amount | Amount payable under the coverage |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication` | coinsurance | Co-insurance | 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%. |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication` | noncovered | Noncovered | 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. |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication` | memberliability | Member liability | The amount of the member's liability. |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication` | discount | Discount | The amount of the discount |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS` | innetwork | In Network | Indicates an in network status in relation to a patient's coverage |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS` | outofnetwork | Out Of Network | Indicates a not in network status in relation to a patient's coverage |  |
`http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS` | negotiated | Negotiated Service or Product | Indicates 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