Bind ExplanationOfBenefit.adjudication.category to PCTAdjudictionCategoryVS (extensible)
Bind ExplanationOfBenefit.item.adjudication.category to PCTAdjudictionCategoryVS (extensible)
Make ExplanationOfBenefit.adjudication MS
Create the following slices on Profile davinci-pct-aeob
Billing Network Status
- ExplanationOfBenefit.adjudication[billingnetworkstatus] 0..1 MS "Billing Provider Network Status"
- With reason codes binding to PCTPayerProviderNetworkStatusVS
Rendering Network Status
- ExplanationOfBenefit.adjudication[renderingnetworkstatus] 0..1 MS "Rendering Provider Network Status"
- With reason codes binding to PCTPayerProviderNetworkStatusVS
Benefit Payment Status
- ExplanationOfBenefit.adjudication[benefitpaymentstatus] 0..1 MS "Benefit Payment Status"
- With reason codes binding to PCTPayerBenefitPaymentStatusVS
- ExplanationOfBenefit.item.adjudication[benefitpaymentstatus] 0..1 MS "Benefit Payment Status" (Description "Line level benefit payment status associated with professional claim estimates only.")
- With reason codes binding to PCTPayerBenefitPaymentStatusVS
Adjustment Reason
- ExplanationOfBenefit.adjudication[adjustmentreason] 0..* MS "Adjustment Reason"
- With reason codes binding to PCTAdjustmentReasonVS
- ExplanationOfBenefit.item.adjudication[adjustmentreason] 0..* MS "Adjustment Reason"
- With reason codes binding to PCTAdjustmentReasonVS
Create the CodeSystem and ValueSet
id: PCTAdjudictionCategory(CS/VS) (Renaming the ValueSet PCTGFEItemAdjudicationVS to PCTAdjudicationCategoryVS and PCTAdjudicationCategoryType to PCTAdjudicationCategoryCS)
Title: PCT Adjudication Category
Description: Codes indicating the type of adjudication information provided.
Codes:
Code |
Display |
Definition |
billingnetworkstatus |
Billing Network Status |
Indicates the Billing Provider network status in relation to the patient's coverage. |
renderingnetworkstatus |
Rendering Network Status |
Indicates the Rendering Provider network status in relation to the patient's coverage. |
benefitpaymentstatus |
Benefit Payment Status |
Indicates the in network or out of network payment status of the claim. |
adjustmentreason |
Adjustment Reason |
Defines the adjudication slice to identify the adjustment reason |
Create the CodeSystem
id: PCTNetworkStatusCS
Title: PCT Network Status
Description: Indicates the network status in relation to a patient's coverage.
Codes:
Code |
Display |
Definition |
innetwork |
In Network |
Indicates an in network status in relation to a patient's coverage |
outofnetwork |
Out Of Network |
Indicates a not in network status in relation to a patient's coverage |
other |
Other |
Indicates other network status or when a network does not apply |
Create the ValueSet
id: PCTPayerProviderNetworkStatusVS
Title: PCT Payer Provider Network Status
Description: Indicates the Provider network status with the Payer as of the effective date of service or admission.
Codes: (from PCTNetworkStatusCS)
Code |
Display |
Definition |
innetwork |
In Network |
Indicates an in network status in relation to a patient's coverage |
outofnetwork |
Out Of Network |
Indicates a not in network status in relation to a patient's coverage |
Create the ValueSet
id: PCTPayerBenefitPaymentStatusVS
Title: PCT Payer Benefit Payment Status
Description: Indicates the in network or out of network payment status of the claim or line item.
Codes: ** (from PCTNetworkStatusCS)
Code |
Display |
Definition |
innetwork |
In Network |
Indicates an in network status in relation to a patient's coverage |
outofnetwork |
Out Of Network |
Indicates a not in network status in relation to a patient's coverage |
other |
Other |
Indicates other network status or when a network does not apply |
Create the ValueSet
id: PCTAdjustmentReasonVS
Title: PCT Adjustment Reason
Description: Codes indicating reasons why a claim or line item is adjusted.
Codes:
All Code Systems defined by the IG in this ticket will have the id appended to with the string "-TEMPORARY-TRIAL-USE"
If CodeSystems and ValueSets are added to THO before approval for publishing, the relevant CodeSystems and ValueSets will be deleted and the binding will be changed appropriately.