This page is part of the Da Vinci Payer Data Exchange (v2.1.0: STU2.1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication | Version: 2.1.0 | |||
| Standards status: Informative | Computable Name: PDexAdjudication | |||
Copyright/Legal: This Valueset is not copyrighted. |
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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 C4BB Adjudication CodeSystem.
References
This value set includes codes based on the following rules:
http://terminology.hl7.org/CodeSystem/adjudication| Code | Display | Definition |
| submitted | Submitted Amount | The total submitted amount for the claim or group or line item. |
| copay | CoPay | Patient Co-Payment |
| eligible | Eligible Amount | Amount of the change which is considered for adjudication. |
| deductible | Deductible | Amount deducted from the eligible amount prior to adjudication. |
| benefit | Benefit Amount | Amount payable under the coverage |
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
| Code | Display | Definition |
| coinsurance | Coinsurance | 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%. |
| 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. |
| priorpayerpaid | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payer. |
| paidbypatient | Paid by patient | The total amount paid by the patient without specifying the source. |
| paidtopatient | Paid to patient | paid to patient |
| paidtoprovider | Paid to provider | The amount paid to the provider. |
| memberliability | Member liability | The amount of the member's liability. |
| discount | Discount | The amount of the discount |
| drugcost | Drug cost | Price paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration |
Expansion performed internally based on:
This value set contains 14 concepts
| Code | System | Display (en-US) | Definition |
| submitted | http://terminology.hl7.org/CodeSystem/adjudication | Submitted Amount | The total submitted amount for the claim or group or line item. |
| copay | http://terminology.hl7.org/CodeSystem/adjudication | CoPay | Patient Co-Payment |
| eligible | http://terminology.hl7.org/CodeSystem/adjudication | Eligible Amount | Amount of the change which is considered for adjudication. |
| deductible | http://terminology.hl7.org/CodeSystem/adjudication | Deductible | Amount deducted from the eligible amount prior to adjudication. |
| benefit | http://terminology.hl7.org/CodeSystem/adjudication | Benefit Amount | Amount payable under the coverage |
| coinsurance | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Coinsurance | 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%. |
| noncovered | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | 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. |
| priorpayerpaid | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payer. |
| paidbypatient | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid by patient | The total amount paid by the patient without specifying the source. |
| paidtopatient | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid to patient | paid to patient |
| paidtoprovider | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid to provider | The amount paid to the provider. |
| memberliability | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Member liability | The amount of the member's liability. |
| discount | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Discount | The amount of the discount |
| drugcost | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Drug cost | Price paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration |
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 |