XIG: ValueSet/PCTAdjudication

FHIR IG Statistics: ValueSet/PCTAdjudication

Package	hl7.fhir.us.davinci-pct
Resource Type	ValueSet
Id	PCTAdjudication
FHIR Version	R4
Source	http://hl7.org/fhir/us/davinci-pct/https://build.fhir.org/ig/HL7/davinci-pct/ValueSet-PCTAdjudication.html
URL	http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication
Version	2.0.0-draft
Status	active
Date	2025-06-03T13:32:08+00:00
Name	PCTAdjudication
Title	PCT Adjudication Value Set
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

ValueSet
PCTTotal	PCT Total Value Set

Resources that this resource uses

CodeSystem
PCTAdjudication	PCT Adjudication Code System
adjudication	Adjudication Value Codes

Narrative

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

Generated Narrative: ValueSet PCTAdjudication

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/davinci-pct/CodeSystem/PCTAdjudication

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.
memberliability	Member liability	The amount of the member's liability.
discount	Discount	The amount of the discount

Source

{
  "resourceType": "ValueSet",
  "id": "PCTAdjudication",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "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/davinci-pct/ImplementationGuide/hl7.fhir.us.davinci-pct"
          }
        ]
      }
    }
  ],
  "url": "http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication",
  "identifier": [
    {
      "system": "urn:ietf:rfc:3986",
      "value": "urn:oid:2.16.840.1.113883.4.642.40.4.48.6"
    }
  ],
  "version": "2.0.0-draft",
  "name": "PCTAdjudication",
  "title": "PCT Adjudication Value Set",
  "status": "active",
  "experimental": false,
  "date": "2025-06-03T13:32:08+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": "fmlists@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/davinci-pct/CodeSystem/PCTAdjudication",
        "concept": [
          {
            "code": "coinsurance",
            "display": "Coinsurance"
          },
          {
            "code": "noncovered",
            "display": "Noncovered"
          },
          {
            "code": "memberliability",
            "display": "Member liability"
          },
          {
            "code": "discount",
            "display": "Discount"
          }
        ]
      }
    ]
  }
}