PDex Adjudication

{
  "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.",
  "compose" : {
    "exclude" : [ ],
    "include" : [ {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "extension" : [ {
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          "valueString" : "concept",
          "url" : "path"
        }, {
          "url" : "count",
          "valueInteger" : 5
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        "url" : "http://health-samurai.io/extensions/excised-data"
      } ]
    }, {
      "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
      "extension" : [ {
        "extension" : [ {
          "valueString" : "concept",
          "url" : "path"
        }, {
          "url" : "count",
          "valueInteger" : 9
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        "url" : "http://health-samurai.io/extensions/excised-data"
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    } ]
  },
  "date" : "2025-06-18T00:57:14+00:00",
  "publisher" : "HL7 International / Financial Management",
  "jurisdiction" : [ {
    "coding" : [ {
      "system" : "urn:iso:std:iso:3166",
      "code" : "US",
      "display" : "United States of America"
    } ]
  } ],
  "name" : "PDexAdjudication",
  "copyright" : "This Valueset is not copyrighted.",
  "experimental" : true,
  "resourceType" : "ValueSet",
  "title" : "PDex Adjudication",
  "extension" : [ {
    "valueCode" : "fm",
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"
  }, {
    "valueCode" : "informative",
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "_valueCode" : {
      "extension" : [ {
        "valueCanonical" : "http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex",
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"
      } ]
    }
  }, {
    "url" : "http://health-samurai.io/extensions/source",
    "valueCode" : "db"
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  "status" : "active",
  "id" : "PDexAdjudication",
  "url" : "http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication",
  "version" : "2.1.0",
  "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"
    } ]
  } ],
  "text" : {
    "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><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/6.3.0/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/6.3.0/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/6.3.0/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/6.3.0/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/6.3.0/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/6.3.0/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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/STU2.1/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>",
    "status" : "extensions"
  }
}