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

ValueSet: PCT Financial Type Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS Version: 2.0.2
Standards status: Trial-use Maturity Level: 2 Computable Name: PCTFinancialTypeVS
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.48.17

Financial Type codes for benefitBalance.financial.type.

References

Changes since version 1.1.0:

  • No changes

    • Logical Definition (CLD)

     

    Expansion

    Expansion performed internally based on codesystem PCT Financial Type Code System v2.0.2 (CodeSystem)

    This value set contains 10 concepts

    SystemCodeDisplay (en)DefinitionJSONXML
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  allowedAllowedThe maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  coinsuranceCo-InsuranceThe 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%.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  copayCoPayA fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  deductibleDeductibleThe amount the insured individual pays for covered health care services before the insurance plan starts to pay.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  eligibleEligible AmountAmount of the charge which is considered for adjudication.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  memberliabilityMember LiabilityThe amount of the member's liability.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  noncoveredNoncoveredThe 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.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  out-of-pocket-maximumOut-of-Pocket MaximumThe 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.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  visitVisitA medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTFinancialType  penaltyPenaltyBenefit 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.

    Description of the above table(s).