Loading...

XML

Word

Printable

JSON

Details

Type: Change Request
Resolution: Persuasive with Modification
Priority: Medium

Specification:

FHIR Core (FHIR)
Raised in Version:

R4
Work Group:

Financial Mgmt
Related URL:
https://www.hl7.org/fhir/codesystem-adjudication.html
Related Page(s):

(NA)
Grouping:
- FM-R5-ToBeApplied
Resolution Description:
Hide

1) Create a new code system that is not an example

2) Add these codes into this code system and make it not an example

3) Review the codes for consistent style

4) In the standard resources we review the bindings, use this code system and make either preferred or extensible.
Show
1) Create a new code system that is not an example 2) Add these codes into this code system and make it not an example 3) Review the codes for consistent style 4) In the standard resources we review the bindings, use this code system and make either preferred or extensible.
Resolution Vote:
Pat Taylor/Gail Kocher: 10-0-0
Change Category:
Enhancement
Change Impact:
Compatible, substantive
Applied for Version:

R5

Description

Add the following values to the Code System Adjudication:

Code	Display	Definition
coinsurance	Co-insurance	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 payor.
paidbypatient	Paid by patient	The amount paid by the patient at the point of service.
paidtoprovider	Paid to provider	The amount paid to the provider.
paidtopatient	Paid to patient	The amount paid to the patient.
memberliability	Member liability	The amount of the member's liability.
coupon-discount	Coupon discount amount	Coupon discount reducing the amount to be collected from the patient
member-discount	Member discount amount	Member discount reducing the amount to be collected from the patient
other-discount	Other discount	Other discount reducing the amount to be collected from the patient
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
other-cost	Other cost	Other amount to be collected from the patient

See attached Excel providing the comparison of the current Adjudiation Code System and those defined by CARIN BB and RTPBC. These IGs define the the following Code Systems:

http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication

http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type