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Resource ValueSet/FHIR Server from package hl7.fhir.us.davinci-pdex#current (32 ms)

Package hl7.fhir.us.davinci-pdex
Type ValueSet
Id Id
FHIR Version R4
Source http://hl7.org/fhir/us/davinci-pdex/https://build.fhir.org/ig/HL7/davinci-epdx/ValueSet-PDexAdjudication.html
Url http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication
Version 2.1.1
Status active
Date 2024-12-06T10:48:58+00:00
Name PDexAdjudication
Title PDex Adjudication
Experimental True
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

StructureDefinition
pdex-priorauthorization PDex Prior Authorization
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator PDex Adjudication Category Discriminator

Resources that this resource uses

CodeSystem
http://terminology.hl7.org/CodeSystem/adjudication Adjudication Value Codes
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication C4BB Adjudication Code System


Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: ValueSet PDexAdjudication

This value set includes codes based on the following rules:

  • Include these codes as defined in http://terminology.hl7.org/CodeSystem/adjudication
    CodeDisplayDefinition
    submittedSubmitted AmountThe total submitted amount for the claim or group or line item.
    copayCoPayPatient Co-Payment
    eligibleEligible AmountAmount of the change which is considered for adjudication.
    deductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
    benefitBenefit AmountAmount payable under the coverage
  • Include these codes as defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
    CodeDisplayDefinition
    coinsuranceCoinsuranceThe 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%.
    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.
    priorpayerpaidPrior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payer.
    paidbypatientPaid by patientThe total amount paid by the patient without specifying the source.
    paidtopatientPaid to patientpaid to patient
    paidtoproviderPaid to providerThe amount paid to the provider.
    memberliabilityMember liabilityThe amount of the member's liability.
    discountDiscountThe amount of the discount
    drugcostDrug costPrice 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" : "PDexAdjudication",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet PDexAdjudication</b></p><a name=\"PDexAdjudication\"> </a><a name=\"hcPDexAdjudication\"> </a><a name=\"PDexAdjudication-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/6.1.0/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/6.1.0/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/6.1.0/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/6.1.0/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/6.1.0/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/6.1.0/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=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/CodeSystem-C4BBAdjudication.html#C4BBAdjudication-paidtopatient\">paidtopatient</a></td><td>Paid to patient</td><td>paid to patient</td></tr><tr><td><a href=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/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=\"http://hl7.org/fhir/us/carin-bb/STU2/CodeSystem-C4BBAdjudication.html#C4BBAdjudication-discount\">discount</a></td><td>Discount</td><td>The amount of the discount</td></tr><tr><td><a href=\"http://hl7.org/fhir/us/carin-bb/STU2/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" : "informative",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication",
  "version" : "2.1.1",
  "name" : "PDexAdjudication",
  "title" : "PDex Adjudication",
  "status" : "active",
  "experimental" : true,
  "date" : "2024-12-06T10:48:58+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"
        }
      ]
    },
    {
      "name" : "Mark Scrimshire (mark.scrimshire@onyxhealth.io)",
      "telecom" : [
        {
          "system" : "email",
          "value" : "mailto:mark.scrimshire@onyxhealth.io"
        }
      ]
    },
    {
      "name" : "HL7 International - Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "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",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "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" : "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"
          }
        ]
      }
    ]
  }
}

XIG built as of ??metadata-date??. Found ??metadata-resources?? resources in ??metadata-packages?? packages.