Patient Cost Transparency Implementation Guide
2.0.2 - 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 2.0.2 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

Page standards status: Trial-use Maturity Level: 2

Raw ttl | Download


@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/ValueSet/PCTAdjudicationVS> a fhir:ValueSet ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "PCTAdjudicationVS"] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ] ;
     fhir:Narrative.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/7.1.0/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><span title=\"Version is explicitly stated to be 1.0.1\"> version ?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/7.1.0/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/7.1.0/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/7.1.0/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/7.1.0/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/7.1.0/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 ?2.0.2</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>"
  ] ;
  fhir:DomainResource.extension [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg" ] ;
     fhir:Extension.valueCode [ fhir:value "fm" ]
  ], [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm" ] ;
     fhir:Extension.valueInteger [
       fhir:value "2"^^xsd:integer ;
       fhir:Element.extension [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom" ] ;
         fhir:Extension.valueCanonical [
           fhir:value "http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct" ;
           fhir:link <http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct>
         ]
       ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status" ] ;
     fhir:Extension.valueCode [
       fhir:value "trial-use" ;
       fhir:Element.extension [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom" ] ;
         fhir:Extension.valueCanonical [
           fhir:value "http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct" ;
           fhir:link <http://hl7.org/fhir/us/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct>
         ]
       ]
     ]
  ] ;
  fhir:ValueSet.url [ fhir:value "http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationVS"] ;
  fhir:ValueSet.identifier [
     fhir:index -1 ;
     fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ] ;
     fhir:Identifier.value [ fhir:value "urn:oid:2.16.840.1.113883.4.642.40.4.48.40" ]
  ] ;
  fhir:ValueSet.version [ fhir:value "2.0.2"] ;
  fhir:ValueSet.name [ fhir:value "PCTAdjudicationVS"] ;
  fhir:ValueSet.title [ fhir:value "PCT Adjudication Value Set"] ;
  fhir:ValueSet.status [ fhir:value "active"] ;
  fhir:ValueSet.experimental [ fhir:value "false"^^xsd:boolean] ;
  fhir:ValueSet.date [ fhir:value "2026-11-09T22:17:29+00:00"^^xsd:dateTime] ;
  fhir:ValueSet.publisher [ fhir:value "HL7 International / Financial Management"] ;
  fhir:ValueSet.contact [
     fhir:index -1 ;
     fhir:ContactDetail.name [ fhir:value "HL7 International / Financial Management" ] ;
     fhir:ContactDetail.telecom [
       fhir:index -1 ;
       fhir:ContactPoint.system [ fhir:value "url" ] ;
       fhir:ContactPoint.value [ fhir:value "http://www.hl7.org/Special/committees/fm" ]
     ], [
       fhir:index -1 ;
       fhir:ContactPoint.system [ fhir:value "email" ] ;
       fhir:ContactPoint.value [ fhir:value "fmlists@lists.hl7.org" ]
     ]
  ] ;
  fhir:ValueSet.description [ fhir:value "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."] ;
  fhir:ValueSet.jurisdiction [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "urn:iso:std:iso:3166" ] ;
       fhir:Coding.code [ fhir:value "US" ]
     ]
  ] ;
  fhir:ValueSet.copyright [ fhir:value "This Valueset is not copyrighted."] ;
  fhir:ValueSet.compose [
     fhir:ValueSet.compose.include [
       fhir:index -1 ;
       fhir:ValueSet.compose.include.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ;
       fhir:ValueSet.compose.include.version [ fhir:value "1.0.1" ] ;
       fhir:ValueSet.compose.include.concept [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "submitted" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "copay" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "eligible" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "deductible" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "benefit" ]
       ]
     ], [
       fhir:index -1 ;
       fhir:ValueSet.compose.include.system [ fhir:value "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication" ] ;
       fhir:ValueSet.compose.include.concept [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "coinsurance" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "noncovered" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "memberliability" ]
       ], [
         fhir:index -1 ;
         fhir:ValueSet.compose.include.concept.code [ fhir:value "discount" ]
       ]
     ]
  ] .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ValueSet/PCTAdjudicationVS.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/ValueSet/PCTAdjudicationVS.ttl> .