Resource ValueSet/FHIR Server from package hl7.fhir.us.carin-bb#current (47 ms)
| Package | hl7.fhir.us.carin-bb |
| Type | ValueSet |
| Id | Id |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/carin-bb/https://build.fhir.org/ig/HL7/carin-bb/ValueSet-C4BBAdjudication.html |
| Url | http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication |
| Version | 2.1.0-snapshot1 |
| Status | active |
| Date | 2024-08-09T18:19:59+00:00 |
| Name | C4BBAdjudication |
| Title | C4BB Adjudication Value Set |
| Experimental | False |
| Realm | us |
| Authority | hl7 |
| Description | 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. |
| Copyright | This Valueset is not copyrighted. |
Resources that use this resource
Resources that this resource uses
Narrative
Note: links and images are rebased to the (stated) source
This value set includes codes based on the following rules:
- Include these codes as defined in
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 |
- Include these codes as defined in
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. |
| paidbypatientcash | Paid by patient - cash | The amount paid by the patient using cash, check, or other personal account. |
| paidbypatientother | Paid by patient - other | The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account. |
| 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 |
Source
{
"resourceType" : "ValueSet",
"id" : "C4BBAdjudication",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet C4BBAdjudication</b></p><a name=\"C4BBAdjudication\"> </a><a name=\"hcC4BBAdjudication\"> </a><a name=\"C4BBAdjudication-en-US\"> </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/6.0.2/CodeSystem-adjudication.html\"><code>http://terminology.hl7.org/CodeSystem/adjudication</code></a><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/6.0.2/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/6.0.2/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/6.0.2/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/6.0.2/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/6.0.2/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-C4BBAdjudication.html\"><code>http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication</code></a><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-C4BBAdjudication.html#C4BBAdjudication-coinsurance\">coinsurance</a></td><td>Coinsurance</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-C4BBAdjudication.html#C4BBAdjudication-noncovered\">noncovered</a></td><td>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-C4BBAdjudication.html#C4BBAdjudication-priorpayerpaid\">priorpayerpaid</a></td><td>Prior payer paid</td><td>The reduction in the payment amount to reflect the carrier as a secondary payer.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatient\">paidbypatient</a></td><td>Paid by patient</td><td>The total amount paid by the patient without specifying the source.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatientcash\">paidbypatientcash</a></td><td>Paid by patient - cash</td><td>The amount paid by the patient using cash, check, or other personal account.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidbypatientother\">paidbypatientother</a></td><td>Paid by patient - other</td><td>The amount paid by the patient using a method different than cash (cash, check, or personal account) or health account.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtopatient\">paidtopatient</a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtoprovider\">paidtoprovider</a></td><td>Paid to provider</td><td>The amount paid to the provider.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-memberliability\">memberliability</a></td><td>Member liability</td><td>The amount of the member's liability.</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td><a href=\"CodeSystem-C4BBAdjudication.html#C4BBAdjudication-drugcost\">drugcost</a></td><td>Drug cost</td><td>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</td></tr></table></li></ul></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode" : "trial-use",
"_valueCode" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/carin-bb/ImplementationGuide/hl7.fhir.us.carin-bb"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication",
"version" : "2.1.0-snapshot1",
"name" : "C4BBAdjudication",
"title" : "C4BB Adjudication Value Set",
"status" : "active",
"experimental" : false,
"date" : "2024-08-09T18:19:59+00:00",
"publisher" : "HL7 International / Financial Management",
"contact" : [
{
"name" : "HL7 International / Financial Management",
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/fm"
},
{
"system" : "email",
"value" : "fm@lists.HL7.org"
}
]
}
],
"description" : "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.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"copyright" : "This Valueset is not copyrighted.",
"compose" : {
"include" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"concept" : [
{
"code" : "submitted"
},
{
"code" : "copay"
},
{
"code" : "eligible"
},
{
"code" : "deductible"
},
{
"code" : "benefit"
}
]
},
{
"system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
"concept" : [
{
"code" : "coinsurance",
"display" : "Coinsurance"
},
{
"code" : "noncovered",
"display" : "Noncovered"
},
{
"code" : "priorpayerpaid",
"display" : "Prior payer paid"
},
{
"code" : "paidbypatient",
"display" : "Paid by patient"
},
{
"code" : "paidbypatientcash",
"display" : "Paid by patient - cash"
},
{
"code" : "paidbypatientother",
"display" : "Paid by patient - other"
},
{
"code" : "paidtopatient",
"display" : "Paid to patient"
},
{
"code" : "paidtoprovider",
"display" : "Paid to provider"
},
{
"code" : "memberliability",
"display" : "Member liability"
},
{
"code" : "discount",
"display" : "Discount"
},
{
"code" : "drugcost",
"display" : "Drug cost"
}
]
}
]
}
}
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