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Recommendation: Add codes, displays and definitions (highlighted in yellow) that are required by rtpbc and carin bb to the HL7 Adjudication Code System. rtpbc and carin bb would each define a new ValueSet: adjudication-rtpbc-value-codes and adjudication-carinbb-value codes, each one selecting the codes it requires from the code system as indicated in columns A and B.
RTPBC Value SetCARIN BB Value SetHL7 Code System: Adjudication example set
CodeDisplayDefinition
yessubmittedSubmitted AmountThe total submitted amount for the claim or group or line item.
yesyescopayCoPayPatient Co-Payment
yeseligibleEligible AmountAmount of the change which is considered for adjudication.
yesyesdeductibleDeductibleAmount deducted from the eligible amount prior to adjudication.
unallocdeductUnallocated DeductibleThe amount of deductible which could not allocated to other line items.
eligpercentEligible %Eligible Percentage.
yestaxTaxThe amount of tax.
yesbenefitBenefit AmountAmount payable under the coverage
yesyescoinsuranceCo-insuranceThe 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%.
yesnoncovered NoncoveredThe 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.
yespriorpayerpaid Prior payer paidThe reduction in the payment amount to reflect the carrier as a secondary payor.
yesyespaidbypatient Paid by patientThe amount paid by the patient at the point of service.
yespaidtoprovider Paid to providerThe amount paid to the provider.
yespaidtopatientPaid to patientThe amount paid to the patient.
yesmemberliabilityMember liabilityThe amount of the member's liability.
yescoupon-discountCoupon discount amountCoupon discount reducing the amount to be collected from the patient
yesmember-discountMember discount amountMember discount reducing the amount to be collected from the patient
yesother-discountOther discountOther discount reducing the amount to be collected from the patient
yesdiscount DiscountThe amount of the discount
yesyesdrugcost Drug 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
yesother-cost Other cost Other amount to be collected from the patient