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 Total Value Set

Official URL: http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal Version: 2.0.2
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

Changes since version 1.1.0:

  • New Content

    • Logical Definition (CLD)

    This value set includes codes based on the following rules:

     

    Expansion

    This value set contains 12 concepts

    SystemCodeDisplay (en)DefinitionJSONXML
    http://terminology.hl7.org/CodeSystem/adjudication  submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
    http://terminology.hl7.org/CodeSystem/adjudication  copayCoPayPatient Co-Payment
    http://terminology.hl7.org/CodeSystem/adjudication  eligibleEligible AmountAmount of the change which is considered for adjudication.
    http://terminology.hl7.org/CodeSystem/adjudication  deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
    http://terminology.hl7.org/CodeSystem/adjudication  benefitBenefit AmountAmount payable under the coverage
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication  coinsuranceCo-insuranceThe 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  noncoveredNoncoveredThe 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  memberliabilityMember liabilityThe amount of the member's liability.
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication  discountDiscountThe amount of the discount
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS  innetworkIn NetworkIndicates an in network status in relation to a patient's coverage
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS  outofnetworkOut Of NetworkIndicates a not in network status in relation to a patient's coverage
    http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS  negotiatedNegotiated Service or ProductIndicates a special negotiated status in relation to a patient's coverage

    Description of the above table(s).