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FHIR IG Statistics: ValueSet/PDexAdjudication

Packagehl7.fhir.us.davinci-pdex
TypeValueSet
IdPDexAdjudication
FHIR VersionR4
Sourcehttp://hl7.org/fhir/us/davinci-pdex/https://build.fhir.org/ig/HL7/davinci-epdx/ValueSet-PDexAdjudication.html
URLhttp://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication
Version2.1.0
Statusactive
Date2025-06-16T14:46:24+00:00
NamePDexAdjudication
TitlePDex Adjudication
Realmus
Authorityhl7
DescriptionDescribes 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.
CopyrightThis Valueset is not copyrighted.

Resources that use this resource

StructureDefinition
pdex-priorauthorizationPDex Prior Authorization
ValueSet
PDexAdjudicationCategoryDiscriminatorPDex Adjudication Category Discriminator

Resources that this resource uses

CodeSystem
adjudicationAdjudication Value Codes
C4BBAdjudicationC4BB Adjudication Code System
adjudicationAdjudication Value Codes

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": "<!-- snip (see above) -->"
  },
  "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": "2.1.0",
  "name": "PDexAdjudication",
  "title": "PDex Adjudication",
  "status": "active",
  "experimental": true,
  "date": "2025-06-16T14:46:24+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"
          }
        ]
      }
    ]
  }
}