An account represents a grouping of financial transactions that are tracked and reported together with a single balance. Examples of account codes (types) are Patient billing accounts (collection of charges), Cost centers; Cash.

An account for collecting charges, reversals, adjustments and payments, including deductibles, copayments, coinsurance (financial transactions) credited or debited to the account receivable account for a patient's encounter.

Description: Types of advance payment to be made on a plastic card usually issued by a financial institution used of purchasing services and/or products.

An account representing charges and credits (financial transactions) for a patient's encounter.

Includes coded responses that will occur as a result of the adjudication of an electronic invoice at a summary level and provides guidance on interpretation of the referenced adjudication results.

Catagorization of grouping criteria for the associated transactions and/or summary (totals, subtotals).

Transaction counts and value totals by Contract Identifier.

Transaction counts and value totals for each calendar day within the date range specified.

Transaction counts and value totals by service location (e.g clinic).

Transaction counts and value totals for each calendar month within the date range specified.

Transaction counts and value totals for the date range specified.

Transaction counts and value totals by Provider Identifier.

Transaction counts and value totals for each calendar week within the date range specified.

Transaction counts and value totals for each calendar year within the date range specified.

The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges).

Also includes the concept 'Adjudicate as zero' and items not covered under a particular Policy.

Invoice element can be reversed (nullified).

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges) without changing the amount.

Invoice element can be reversed (nullified).

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

The invoice element has passed through the adjudication process but payment is refused due to one or more reasons.

Includes items such as patient not covered, or invoice element is not constructed according to payer rules (e.g. 'invoice submitted too late').

If one invoice element line item in the invoice element structure is rejected, the remaining line items may not be adjudicated and the complete group is treated as rejected.

A refused invoice element can be forwarded to the next payer (for Coordination of Benefits) or modified and resubmitted to refusing payer.

Invoice element cannot be reversed (nullified) as there is nothing to reverse.

Recommend that the invoice element is not saved for DUR (Drug Utilization Reporting).

The invoice element was/will be paid exactly as submitted, without financial adjustment(s).

If the dollar amount stays the same, but the billing codes have been amended or financial adjustments have been applied through the adjudication process, the invoice element is treated as "Adjudicated with Adjustment".

If information items are included in the adjudication results that do not affect the monetary amounts paid, then this is still Adjudicated as Submitted (e.g. 'reached Plan Maximum on this Claim').

Invoice element can be reversed (nullified).

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).

Actions to be carried out by the recipient of the Adjudication Result information.

The adjudication result associated is to be displayed to the receiver of the adjudication result.

The adjudication result associated is to be printed on the specified form, which is then provided to the covered party.

**Definition:**An identifying modifier code for healthcare interventions or procedures.

**Description:**CPT modifier codes are found in Appendix A of CPT 2000 Standard Edition.

**Description:**HCPCS Level II (HCFA-assigned) and Carrier-assigned (Level III) modifiers are reported in Appendix A of CPT 2000 Standard Edition and in the Medicare Bulletin.

The type of provision(s) made for reimbursing for the deliver of healthcare services and/or goods provided by a Provider, over a specified period.

A billing arrangement where a Provider charges a lump sum to provide a prescribed group (volume) of services to a single patient which occur over a period of time. Services included in the block may vary.

This billing arrangement is also known as Program of Care for some specific Payors and Program Fees for other Payors.

A billing arrangement where the payment made to a Provider is determined by analyzing one or more demographic attributes about the persons/patients who are enrolled with the Provider (in their practice).

A billing arrangement where a Provider charges a lump sum to provide a particular volume of one or more interventions/procedures or groups of interventions/procedures.

A billing arrangement where a Provider charges for non-clinical items. This includes interest in arrears, mileage, etc. Clinical content is not included in Invoices submitted with this type of billing arrangement.

A billing arrangement where funding is based on a list of individuals registered as patients of the Provider.

A billing arrangement where a Provider charges a sum to provide a group (volume) of interventions/procedures to one or more patients within a defined period of time, typically on the same date. Interventions/procedures included in the session may vary.

A billing arrangement where a Provider charges a separate fee for each intervention/procedure/event or product.

Fee for Service is used when an individual intervention/procedure/event is used for billing purposes. In other words, fees are associated with the intervention/procedure/event. For example, a specific CCI (Canadian Classification of Interventions) code has an associated fee and is used for billing purposes.

A first fill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets)

A first fill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).

A fill where a small portion is provided to allow for determination of the therapy effectiveness and patient tolerance and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).

Type of bounded ROI.

A fully specified bounded Region of Interest (ROI) delineates a ROI in which only those dimensions participate that are specified by boundary criteria, whereas all other dimensions are excluded. For example a ROI to mark an episode of "ST elevation" in a subset of the EKG leads V2, V3, and V4 would include 4 boundaries, one each for time, V2, V3, and V4.

A partially specified bounded Region of Interest (ROI) specifies a ROI in which at least all values in the dimensions specified by the boundary criteria participate. For example, if an episode of ventricular fibrillations (VFib) is observed, it usually doesn't make sense to exclude any EKG leads from the observation and the partially specified ROI would contain only one boundary for time indicating the time interval where VFib was observed.

**Description:**The type and scope of responsibility taken-on by the performer of the Act for a specific subject of care.

**Description:**The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by a credentialing agency, i.e. government or non-government agency. Failure in executing this Act may result in loss of credential to the person or organization who participates as performer of the Act. Excludes employment agreements.

**Example:**Hospital license; physician license; clinic accreditation.

**Description:**The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by an agency for credentialing individuals.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.

**Description:**Scope of responsibility taken-on for physician care of a patient as defined by a governmental licensing agency.

**Description:**The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by an agency for credentialing programs within organizations.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

Description:.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.

Domain provides codes that qualify the ActEncounterClass (ENC)

A comprehensive term for health care provided in a healthcare facility (e.g. a practitioneraTMs office, clinic setting, or hospital) on a nonresident basis. The term ambulatory usually implies that the patient has come to the location and is not assigned to a bed. Sometimes referred to as an outpatient encounter.

A patient encounter that takes place at a dedicated healthcare service delivery location where the patient receives immediate evaluation and treatment, provided until the patient can be discharged or responsibility for the patient's care is transferred elsewhere (for example, the patient could be admitted as an inpatient or transferred to another facility.)

A patient encounter that takes place both outside a dedicated service delivery location and outside a patient's residence. Example locations might include an accident site and at a supermarket.

Healthcare encounter that takes place in the residence of the patient or a designee

A patient encounter where a patient is admitted by a hospital or equivalent facility, assigned to a location where patients generally stay at least overnight and provided with room, board, and continuous nursing service.

An acute inpatient encounter.

Any category of inpatient encounter except 'acute'

An encounter where the patient usually will start in different encounter, such as one in the emergency department (EMER) but then transition to this type of encounter because they require a significant period of treatment and monitoring to determine whether or not their condition warrants an inpatient admission or discharge. In the majority of cases the decision about admission or discharge will occur within a time period determined by local, regional or national regulation, often between 24 and 48 hours.

A patient encounter where patient is scheduled or planned to receive service delivery in the future, and the patient is given a pre-admission account number. When the patient comes back for subsequent service, the pre-admission encounter is selected and is encapsulated into the service registration, and a new account number is generated.

Usage Note: This is intended to be used in advance of encounter types such as ambulatory, inpatient encounter, virtual, etc.

An encounter where the patient is admitted to a health care facility for a predetermined length of time, usually less than 24 hours.

A patient encounter where the patient and the practitioner(s) are not in the same physical location. Examples include telephone conference, email exchange, robotic surgery, and televideo conference.

General category of medical service provided to the patient during their encounter.

Provision of Alternate Level of Care to a patient in an acute bed. Patient is waiting for placement in a long-term care facility and is unable to return home.

Provision of diagnosis and treatment of diseases and disorders affecting the heart

Provision of recurring care for chronic illness.

Provision of treatment for oral health and/or dental surgery.

Provision of treatment for drug abuse.

General care performed by a general practitioner or family doctor as a responsible provider for a patient.

Provision of diagnostic and/or therapeutic treatment.

Provision of care of women during pregnancy, childbirth and immediate postpartum period. Also known as Maternity.

Provision of treatment and/or diagnosis related to tumors and/or cancer.

Provision of care for patients who are living or dying from an advanced illness.

Provision of diagnosis and treatment of diseases and disorders affecting children.

Pharmaceutical care performed by a pharmacist.

Provision of treatment for physical injury.

Provision of treatment of psychiatric disorder relating to mental illness.

Provision of surgical treatment.

Description: Coded types of attachments included to support a healthcare claim.

Description: Automobile Information Attachment

Description: Document Attachment

Description: Health Record Attachment

Description: Image Attachment

Description: Lab Results Attachment

Description: Digital Model Attachment

Description: Work Injury related additional Information Attachment

Description: Digital X-Ray Attachment

Definition: The type of consent directive, e.g., to consent or dissent to collect, access, or use in specific ways within an EHRS or for health information exchange; or to disclose health information for purposes such as research.

Definition: Consent to have healthcare information collected in an electronic health record. This entails that the information may be used in analysis, modified, updated.

Definition: Consent to have collected healthcare information disclosed.

Definition: Consent to access healthcare information.

Definition: Consent to access or "read" only, which entails that the information is not to be copied, screen printed, saved, emailed, stored, re-disclosed or altered in any way. This level ensures that data which is masked or to which access is restricted will not be.

Example: Opened and then emailed or screen printed for use outside of the consent directive purpose.

Definition: Consent to access and save only, which entails that access to the saved copy will remain locked.

Definition: Information re-disclosed without the patient's consent.

Definition: Consent to have healthcare information in an electronic health record accessed for research purposes.

Definition: Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes, but without consent to re-identify the information under any circumstance.

Definition: Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes re-identified under specific circumstances outlined in the consent.

Example:: Where there is a need to inform the subject of potential health issues.

Constrains the ActCode to the domain of Container Registration

Used by one system to inform another that it has received a container.

Used by one system to inform another that the container is in position for specimen transfer (e.g., container removal from track, pipetting, etc.).

Used by one system to inform another that the container has been released from that system.

Used by one system to inform another that the container did not arrive at its next expected location.

Used by one system to inform another that the specific container is being processed by the equipment. It is useful as a response to a query about Container Status, when the specific step of the process is not relevant.

Status is used by one system to inform another that the processing has been completed, but the container has not been released from that system.

Used by one system to inform another that the container is no longer available within the scope of the system (e.g., tube broken or discarded).

An observation form that determines parameters or attributes of an Act. Examples are the settings of a ventilator machine as parameters of a ventilator treatment act; the controls on dillution factors of a chemical analyzer as a parameter of a laboratory observation act; the settings of a physiologic measurement assembly (e.g., time skew) or the position of the body while measuring blood pressure.

Control variables are forms of observations because just as with clinical observations, the Observation.code determines the parameter and the Observation.value assigns the value. While control variables sometimes can be observed (by noting the control settings or an actually measured feedback loop) they are not primary observations, in the sense that a control variable without a primary act is of no use (e.g., it makes no sense to record a blood pressure position without recording a blood pressure, whereas it does make sense to record a systolic blood pressure without a diastolic blood pressure).

Specifies whether or not automatic repeat testing is to be initiated on specimens.

A baseline value for the measured test that is inherently contained in the diluent. In the calculation of the actual result for the measured test, this baseline value is normally considered.

Specifies whether or not further testing may be automatically or manually initiated on specimens.

Response to an insurance coverage eligibility query or authorization request.

Indication of authorization for healthcare service(s) and/or product(s). If authorization is approved, funds are set aside.

Authorization approved and funds have been set aside to pay for specified healthcare service(s) and/or product(s) within defined criteria for the authorization.

Authorization for specified healthcare service(s) and/or product(s) denied.

Indication of eligibility coverage for healthcare service(s) and/or product(s).

Insurance coverage is in effect for healthcare service(s) and/or product(s).

Insurance coverage is not in effect for healthcare service(s) and/or product(s). May optionally include reasons for the ineligibility.

Criteria that are applicable to the authorized coverage.

Maximum amount paid or maximum number of services/products covered; or maximum amount or number covered during a specified time period under the policy or program.

Codes representing the time period during which coverage is available; or financial participation requirements are in effect.

Definition: Maximum amount paid by payer or covered party; or maximum number of services or products covered under the policy or program during a covered party's lifetime.

Maximum net amount that will be covered for the product or service specified.

Definition: Maximum amount paid by payer or covered party; or maximum number of services/products covered under the policy or program by time period specified by the effective time on the act.

Maximum unit price that will be covered for the authorized product or service.

Maximum number of items that will be covered of the product or service specified.

Definition: Codes representing the maximum coverate or financial participation requirements.

Codes representing the types of covered parties that may receive covered benefits under a policy or program.

Codes representing the level of coverage provided under the policy or program in terms of the types of entities that may play covered parties based on their personal relationships or employment status.

Definition: Set of codes indicating the type of insurance policy or program that pays for the cost of benefits provided to covered parties.

Set of codes indicating the type of insurance policy or other source of funds to cover healthcare costs.

Private insurance policy that provides coverage in addition to other policies (e.g. in addition to a Public Healthcare insurance policy).

Insurance policy that provides for an allotment of funds replenished on a periodic (e.g. annual) basis. The use of the funds under this policy is at the discretion of the covered party.

Insurance policy for injuries sustained in an automobile accident. Will also typically covered non-named parties to the policy, such as pedestrians and passengers.

Definition: An automobile insurance policy under which the insurance company will cover the cost of damages to an automobile owned by the named insured that are caused by accident or intentionally by another party.

Definition: An automobile insurance policy under which the insurance company will indemnify a loss for which another motorist is liable if that motorist is unable to pay because he or she is uninsured. Coverage under the policy applies to bodily injury damages only. Injuries to the covered party caused by a hit-and-run driver are also covered.

Insurance policy funded by a public health system such as a provincial or national health plan. Examples include BC MSP (British Columbia Medical Services Plan) OHIP (Ontario Health Insurance Plan), NHS (National Health Service).

Definition: A public or government health program that administers and funds coverage for dental care to assist program eligible who meet financial and health status criteria.

Definition: A public or government health program that administers and funds coverage for health and social services to assist program eligible who meet financial and health status criteria related to a particular disease.

Example: Reproductive health, sexually transmitted disease, and end renal disease programs.

Definition: A program that provides low-income, uninsured, and underserved women access to timely, high-quality screening and diagnostic services, to detect breast and cervical cancer at the earliest stages.

Example: To improve women's access to screening for breast and cervical cancers, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990, which guided CDC in creating the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides access to critical breast and cervical cancer screening services for underserved women in the United States. An estimated 7 to 10% of U.S. women of screening age are eligible to receive NBCCEDP services. Federal guidelines establish an eligibility baseline to direct services to uninsured and underinsured women at or below 250% of federal poverty level; ages 18 to 64 for cervical screening; ages 40 to 64 for breast screening.

Definition: A public or government program that administers publicly funded coverage of kidney dialysis and kidney transplant services.

Example: In the U.S., the Medicare End-stage Renal Disease program (ESRD), the National Kidney Foundation (NKF) American Kidney Fund (AKF) The Organ Transplant Fund.

Definition: Government administered and funded HIV-AIDS program for beneficiaries meeting financial and health status criteria. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors.

Example: In the U.S., the Ryan White program, which is administered by the Health Resources and Services Administration.

Definition: Government administered and funded mental health program for beneficiaries meeting financial and mental health status criteria. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors.

Example: In the U.S., states receive funding for substance use programs from the Substance Abuse Mental Health Administration (SAMHSA).

Definition: Government administered and funded program to support provision of care to underserved populations through safety net clinics.

Example: In the U.S., safety net providers such as federally qualified health centers (FQHC) receive funding under PHSA Section 330 grants administered by the Health Resources and Services Administration.

Definition: Government administered and funded substance use program for beneficiaries meeting financial, substance use behavior, and health status criteria. Beneficiaries may be required to enroll as a result of legal proceedings. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors.

Example: In the U.S., states receive funding for substance use programs from the Substance Abuse Mental Health Administration (SAMHSA).

Definition: A government health program that provides coverage for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds.

Definition: A government health program that provides coverage through managed care contracts for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds.

Discussion: The structure and business processes for underwriting and administering a subsidized managed care program is further specified by the Underwriter and Payer Role.class and Role.code.

Definition: A government health program that provides coverage for health services to persons meeting eligibility criteria for a supplemental health policy or program such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds.

Example: Supplemental health coverage program may cover the cost of a health program or policy financial participations, such as the copays and the premiums, and may provide coverage for services in addition to those covered under the supplemented health program or policy. In the U.S., Medicaid programs may pay the premium for a covered party who is also covered under the Medicare program or a private health policy.

Discussion: The structure and business processes for underwriting and administering a subsidized supplemental retiree health program is further specified by the Underwriter and Payer Role.class and Role.code.

Insurance policy for injuries sustained in the work place or in the course of employment.

Definition: Set of codes indicating the type of insurance policy. Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of potential financial loss. Insurance is defined as the equitable transfer of the risk of a potential loss, from one entity to another, in exchange for a premium and duty of care. A policy holder is an individual or an organization enters into a contract with an underwriter which stipulates that, in exchange for payment of a sum of money (a premium), one or more covered parties (insureds) is guaranteed compensation for losses resulting from certain perils under specified conditions. The underwriter analyzes the risk of loss, makes a decision as to whether the risk is insurable, and prices the premium accordingly. A policy provides benefits that indemnify or cover the cost of a loss incurred by a covered party, and may include coverage for services required to remediate a loss. An insurance policy contains pertinent facts about the policy holder, the insurance coverage, the covered parties, and the insurer. A policy may include exemptions and provisions specifying the extent to which the indemnification clause cannot be enforced for intentional tortious conduct of a covered party, e.g., whether the covered parties are jointly or severably insured.

Discussion: In contrast to programs, an insurance policy has one or more policy holders, who own the policy. The policy holder may be the covered party, a relative of the covered party, a partnership, or a corporation, e.g., an employer. A subscriber of a self-insured health insurance policy is a policy holder. A subscriber of an employer sponsored health insurance policy is holds a certificate of coverage, but is not a policy holder; the policy holder is the employer. See CoveredRoleType.

Definition: Set of codes indicating the type of health insurance policy that covers health services provided to covered parties. A health insurance policy is a written contract for insurance between the insurance company and the policyholder, and contains pertinent facts about the policy owner (the policy holder), the health insurance coverage, the insured subscribers and dependents, and the insurer. Health insurance is typically administered in accordance with a plan, which specifies (1) the type of health services and health conditions that will be covered under what circumstances (e.g., exclusion of a pre-existing condition, service must be deemed medically necessary; service must not be experimental; service must provided in accordance with a protocol; drug must be on a formulary; service must be prior authorized; or be a referral from a primary care provider); (2) the type and affiliation of providers (e.g., only allopathic physicians, only in network, only providers employed by an HMO); (3) financial participations required of covered parties (e.g., co-pays, coinsurance, deductibles, out-of-pocket); and (4) the manner in which services will be paid (e.g., under indemnity or fee-for-service health plans, the covered party typically pays out-of-pocket and then file a claim for reimbursement, while health plans that have contractual relationships with providers, i.e., network providers, typically do not allow the providers to bill the covered party for the cost of the service until after filing a claim with the payer and receiving reimbursement).

Definition: A health insurance policy that that covers benefits for dental services.

Definition: A health insurance policy that covers benefits for healthcare services provided for named conditions under the policy, e.g., cancer, diabetes, or HIV-AIDS.

Definition: A health insurance policy that covers benefits for prescription drugs, pharmaceuticals, and supplies.

Definition: A health insurance policy that covers healthcare benefits by protecting covered parties from medical expenses arising from health conditions, sickness, or accidental injury as well as preventive care. Health insurance policies explicitly exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy.

Discussion: Health insurance policies are offered by health insurance plans that typically reimburse providers for covered services on a fee-for-service basis, that is, a fee that is the allowable amount that a provider may charge. This is in contrast to managed care plans, which typically prepay providers a per-member/per-month amount or capitation as reimbursement for all covered services rendered. Health insurance plans include indemnity and healthcare services plans.

Definition: An insurance policy that covers benefits for long-term care services people need when they no longer can care for themselves. This may be due to an accident, disability, prolonged illness or the simple process of aging. Long-term care services assist with activities of daily living including:

• Help at home with day-to-day activities, such as cooking, cleaning, bathing and dressing
• Care in the community, such as in an adult day care facility
• Supervised care provided in an assisted living facility
• Skilled care provided in a nursing home

Definition: Government mandated program providing coverage, disability income, and vocational rehabilitation for injuries sustained in the work place or in the course of employment. Employers may either self-fund the program, purchase commercial coverage, or pay a premium to a government entity that administers the program. Employees may be required to pay premiums toward the cost of coverage as well.

Managed care policies specifically exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy.

Discussion: Managed care policies are offered by managed care plans that contract with selected providers or health care organizations to provide comprehensive health care at a discount to covered parties and coordinate the financing and delivery of health care. Managed care uses medical protocols and procedures agreed on by the medical profession to be cost effective, also known as medical practice guidelines. Providers are typically reimbursed for covered services by a capitated amount on a per member per month basis that may reflect difference in the health status and level of services anticipated to be needed by the member.

Definition: A policy for a health plan that provides coverage for health care only through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Eligibility to enroll in an HMO is determined by where a covered party lives or works.

Definition: A network-based, managed care plan that allows a covered party to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverage and lower deductibles.

Definition: A health insurance policy that covers benefits for mental health services and prescriptions.

Definition: A policy for a health plan that has features of both an HMO and a FFS plan. Like an HMO, a POS plan encourages the use its HMO network to maintain discounted fees with participating providers, but recognizes that sometimes covered parties want to choose their own provider. The POS plan allows a covered party to use providers who are not part of the HMO network (non-participating providers). However, there is a greater cost associated with choosing these non-network providers. A covered party will usually pay deductibles and coinsurances that are substantially higher than the payments when he or she uses a plan provider. Use of non-participating providers often requires the covered party to pay the provider directly and then to file a claim for reimbursement, like in an FFS plan.

Definition: A health insurance policy that covers benefits for substance use services.

Definition: Set of codes for a policy that provides coverage for health care expenses arising from vision services.

A health insurance policy that covers benefits for vision care services, prescriptions, and products.

Definition: An insurance policy that provides a regular payment to compensate for income lost due to the covered party's inability to work because of illness or injury.

Definition: An insurance policy under a benefit plan run by an employer or employee organization for the purpose of providing benefits other than pension-related to employees and their families. Typically provides health-related benefits, benefits for disability, disease or unemployment, or day care and scholarship benefits, among others. An employer sponsored health policy includes coverage of health care expenses arising from sickness or accidental injury, coverage for on-site medical clinics or for dental or vision benefits, which are typically provided under a separate policy. Coverage excludes health care expenses covered by accident or disability, workers' compensation, liability or automobile insurance.

Definition: An insurance policy that covers qualified benefits under a Flexible Benefit plan such as group medical insurance, long and short term disability income insurance, group term life insurance for employees only up to $50,000 face amount, specified disease coverage such as a cancer policy, dental and/or vision insurance, hospital indemnity insurance, accidental death and dismemberment insurance, a medical expense reimbursement plan and a dependent care reimbursement plan.

Discussion: See UnderwriterRoleTypeCode flexible benefit plan which is defined as a benefit plan that allows employees to choose from several life, health, disability, dental, and other insurance plans according to their individual needs. Also known as cafeteria plans. Authorized under Section 125 of the Revenue Act of 1978.

Definition: A policy under which the insurer agrees to pay a sum of money upon the occurrence of the covered partys death. In return, the policyholder agrees to pay a stipulated amount called a premium at regular intervals. Life insurance indemnifies the beneficiary for the loss of the insurable interest that a beneficiary has in the life of a covered party. For persons related by blood, a substantial interest established through love and affection, and for all other persons, a lawful and substantial economic interest in having the life of the insured continue. An insurable interest is required when purchasing life insurance on another person. Specific exclusions are often written into the contract to limit the liability of the insurer; for example claims resulting from suicide or relating to war, riot and civil commotion.

*Discussion:*A life insurance policy may be used by the covered party as a source of health care coverage in the case of a viatical settlement, which is the sale of a life insurance policy by the policy owner, before the policy matures. Such a sale, at a price discounted from the face amount of the policy but usually in excess of the premiums paid or current cash surrender value, provides the seller an immediate cash settlement. Generally, viatical settlements involve insured individuals with a life expectancy of less than two years. In countries without state-subsidized healthcare and high healthcare costs (e.g. United States), this is a practical way to pay extremely high health insurance premiums that severely ill people face. Some people are also familiar with life settlements, which are similar transactions but involve insureds with longer life expectancies (two to fifteen years).

Definition: A policy that, after an initial premium or premiums, pays out a sum at pre-determined intervals.

For example, a policy holder may pay $10,000, and in return receive $150 each month until he dies; or $1,000 for each of 14 years or death benefits if he dies before the full term of the annuity has elapsed.

Definition: Life insurance under which the benefit is payable only if the insured dies during a specified period. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing.

Definition: Life insurance under which the benefit is payable upon the insuredaTMs death or diagnosis of a terminal illness. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing

Definition: A type of insurance that covers damage to or loss of the policyholderaTMs property by providing payments for damages to property damage or the injury or death of living subjects. The terms "casualty" and "liability" insurance are often used interchangeably. Both cover the policyholder's legal liability for damages caused to other persons and/or their property.

Definition: An agreement between two or more insurance companies by which the risk of loss is proportioned. Thus the risk of loss is spread and a disproportionately large loss under a single policy does not fall on one insurance company. Acceptance by an insurer, called a reinsurer, of all or part of the risk of loss of another insurance company.

Discussion: Reinsurance is a means by which an insurance company can protect itself against the risk of losses with other insurance companies. Individuals and corporations obtain insurance policies to provide protection for various risks (hurricanes, earthquakes, lawsuits, collisions, sickness and death, etc.). Reinsurers, in turn, provide insurance to insurance companies.

For example, an HMO may purchase a reinsurance policy to protect itself from losing too much money from one insured's particularly expensive health care costs. An insurance company issuing an automobile liability policy, with a limit of $100,000 per accident may reinsure its liability in excess of $10,000. A fire insurance company which issues a large policy generally reinsures a portion of the risk with one or several other companies. Also called risk control insurance or stop-loss insurance.

Definition:

1. A risk or part of a risk for which there is no normal insurance market available.
2. Insurance written by unauthorized insurance companies. Surplus lines insurance is insurance placed with unauthorized insurance companies through licensed surplus lines agents or brokers.

Definition: A form of insurance protection that provides additional liability coverage after the limits of your underlying policy are reached. An umbrella liability policy also protects you (the insured) in many situations not covered by the usual liability policies.

Definition: A set of codes used to indicate coverage under a program. A program is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health, financial, and demographic status. Programs are typically established or permitted by legislation with provisions for ongoing government oversight. Regulations may mandate the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency may be charged with implementing the program in accordance to the regulation. Risk of loss under a program in most cases would not meet what an underwriter would consider an insurable risk, i.e., the risk is not random in nature, not financially measurable, and likely requires subsidization with government funds.

Discussion: Programs do not have policy holders or subscribers. Program eligibles are enrolled based on health status, statutory eligibility, financial status, or age. Program eligibles who are covered parties under the program may be referred to as members, beneficiaries, eligibles, or recipients. Programs risk are underwritten by not for profit organizations such as governmental entities, and the beneficiaries typically do not pay for any or some portion of the cost of coverage. See CoveredPartyRoleType.

Definition: A program that covers the cost of services provided directly to a beneficiary who typically has no other source of coverage without charge.

Definition: A program that covers the cost of services provided to crime victims for injuries or losses related to the occurrence of a crime.

Definition: An employee assistance program is run by an employer or employee organization for the purpose of providing benefits and covering all or part of the cost for employees to receive counseling, referrals, and advice in dealing with stressful issues in their lives. These may include substance abuse, bereavement, marital problems, weight issues, or general wellness issues. The services are usually provided by a third-party, rather than the company itself, and the company receives only summary statistical data from the service provider. Employee's names and services received are kept confidential.

Definition: A set of codes used to indicate a government program that is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health and financial status. Government programs are established or permitted by legislation with provisions for ongoing government oversight. Regulation mandates the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency is charged with implementing the program in accordance to the regulation

Example: Federal employee health benefit program in the U.S.

Definition: A government program that provides health coverage to individuals who are considered medically uninsurable or high risk, and who have been denied health insurance due to a serious health condition. In certain cases, it also applies to those who have been quoted very high premiums a" again, due to a serious health condition. The pool charges premiums for coverage. Because the pool covers high-risk people, it incurs a higher level of claims than premiums can cover. The insurance industry pays into the pool to make up the difference and help it remain viable.

Definition: Services provided directly and through contracted and operated indigenous peoples health programs.

Example: Indian Health Service in the U.S.

Definition: A government program that provides coverage for health services to military personnel, retirees, and dependents. A covered party who is a subscriber can choose from among Fee-for-Service (FFS) plans, and their Preferred Provider Organizations (PPO), or Plans offering a Point of Service (POS) Product, or Health Maintenance Organizations.

Example: In the U.S., TRICARE, CHAMPUS.

Definition: A government mandated program with specific eligibility requirements based on premium contributions made during employment, length of employment, age, and employment status, e.g., being retired, disabled, or a dependent of a covered party under this program. Benefits typically include ambulatory, inpatient, and long-term care, such as hospice care, home health care and respite care.

Definition: A social service program funded by a public or governmental entity.

Example: Programs providing habilitation, food, lodging, medicine, transportation, equipment, devices, products, education, training, counseling, alteration of living or work space, and other resources to persons meeting eligibility criteria.

Definition: Services provided directly and through contracted and operated veteran health programs.

Codes dealing with the management of Detected Issue observations

Codes dealing with the management of Detected Issue observations for the administrative and patient administrative acts domains.

Used to temporarily override normal authorization rules to gain access to data in a case of emergency. Use of this override code will typically be monitored, and a procedure to verify its proper use may be triggered when used.

Description: Indicates that the permissions have been externally verified and the request should be processed.

Confirmed drug therapy appropriate

Consulted other supplier/pharmacy, therapy confirmed

Assessed patient, therapy is appropriate

Description: The patient has the appropriate indication or diagnosis for the action to be taken.

Description: It has been confirmed that the appropriate pre-requisite therapy has been tried.

Patient gave adequate explanation

Consulted other supply source, therapy still appropriate

Consulted prescriber, therapy confirmed

Consulted prescriber and recommended change, prescriber declined

Concurrent therapy triggering alert is no longer on-going or planned

Confirmed supply action appropriate

Patient's existing supply was lost/wasted

Supply date is due to patient vacation

Supply date is intended to carry patient over weekend

Supply is intended for use during a leave of absence from an institution.

Description: Supply is different than expected as an additional quantity has been supplied in a separate dispense.

Order is performed as issued, but other action taken to mitigate potential adverse effects

Provided education or training to the patient on appropriate therapy use

Instituted an additional therapy to mitigate potential negative effects

Suspended existing therapy that triggered interaction for the duration of this therapy

Aborted existing therapy that triggered interaction.

Arranged to monitor patient for adverse effects

Codes dealing with the management of Detected Issue observations for the financial acts domain.

Concepts that identify the type or nature of exposure interaction. Examples include "household", "care giver", "intimate partner", "common space", "common substance", etc. to further describe the nature of interaction.

Description: Exposure participants' interaction occurred in a child care setting

Description: An interaction where the exposure participants traveled in/on the same vehicle (not necessarily concurrently, e.g. both are passengers of the same plane, but on different flights of that plane).

Description: Exposure participants' interaction occurred during the course of health care delivery or in a health care delivery setting, but did not involve the direct provision of care (e.g. a janitor cleaning a patient's hospital room).

Description: Exposure interaction occurred in context of one providing care for the other, i.e. a babysitter providing care for a child, a home-care aide providing assistance to a paraplegic.

Description: Exposure participants' interaction occurred when both were patients being treated in the same (acute) health care delivery facility.

Description: Exposure participants' interaction occurred when one visited the other who was a patient being treated in a health care delivery facility.

Description: Exposure interaction occurred in context of domestic interaction, i.e. both participants reside in the same household.

Description: Exposure participants' interaction occurred in the course of one or both participants being incarcerated at a correctional facility

Description: Exposure interaction was intimate, i.e. participants are intimate companions (e.g. spouses, domestic partners).

Description: Exposure participants' interaction occurred in the course of one or both participants being resident at a long term care facility (second participant may be a visitor, worker, resident or a physical place or object within the facility).

Description: An interaction where the exposure participants were both present in the same location/place/space.

Description: Exposure participants' interaction occurred during the course of health care delivery by a provider (e.g. a physician treating a patient in her office).

Description: Exposure participants' interaction occurred in an academic setting (e.g., participants are fellow students, or student and teacher).

Description: An interaction where the exposure participants are social associates or members of the same extended family

Description: An interaction where the exposure participants shared or co-used a common substance (e.g. drugs, needles, or common food item).

Description: An interaction where the exposure participants traveled together in/on the same vehicle/trip (e.g. concurrent co-passengers).

Description: Exposure interaction occurred in a work setting, i.e. participants are co-workers.

A type of transaction that represents a charge for a service or product. Expressed in monetary terms.

A type of transaction that represents a reversal of a previous charge for a service or product. Expressed in monetary terms. It has the opposite effect of a standard charge.

Set of codes indicating the type of incident or accident.

Incident or accident as the result of a motor vehicle accident

Incident or accident is the result of a school place accident.

Incident or accident is the result of a sporting accident.

Incident or accident is the result of a work place accident

Definition: A code specifying the particular kind of Patient Safety Incident that the Incident class instance represents.

Examples:"Medication incident", "slips, trips and falls incident".The actual value set for the domain will be determined by each (realm) implementation, whose Patient Safety terminology will be specific, although probably linked to the WHO Patient Safety Taxonomy that is currently under development

Description: The type of health information to which the subject of the information or the subject's delegate consents or dissents.

Description: Provide consent to collect, use, disclose, or access adverse drug reaction information for a patient.

Description: Provide consent to collect, use, disclose, or access all information for a patient.

Description: Provide consent to collect, use, disclose, or access allergy information for a patient.

Description: Provide consent to collect, use, disclose, or access informational consent information for a patient.

Description: Provide consent to collect, use, disclose, or access demographics information for a patient.

Description: Provide consent to collect, use, disclose, or access diagnostic imaging information for a patient.

Description: Provide consent to collect, use, disclose, or access immunization information for a patient.

Description: Provide consent to collect, use, disclose, or access lab test result information for a patient.

Description: Provide consent to collect, use, disclose, or access medical condition information for a patient.

Definition: Provide consent to view or access medical condition information for a patient.

**Description:**Provide consent to collect, use, disclose, or access mental health information for a patient.

Description: Provide consent to collect, use, disclose, or access common observation information for a patient.

Description: Provide consent to collect, use, disclose, or access coverage policy or program for a patient.

Description: Provide consent to collect, use, disclose, or access provider information for a patient.

Description: Provide consent to collect, use, disclose, or access professional service information for a patient.

**Description:**Provide consent to collect, use, disclose, or access substance abuse information for a patient.

Concepts conveying the context in which authorization given under jurisdictional law, by organizational policy, or by a patient consent directive permits the collection, access, use or disclosure of specified patient health information.

Authorization to collect, access, use, or disclose specified patient health information in accordance with jurisdictional law, organizational policy, or a patient's consent directive, which may be implied, deemed, opt-in, opt-out, or explicit.

Authorization to collect, access, use, or disclose specified patient health information as explicitly consented to by the subject of the information or the subject's representative.

Authorization to collect, access, use, or disclose specified patient health information in accordance with judicial system protocol, such as in the case of a subpoena or court order.

Authorization to collect, access, use, or disclose specified patient health information where deemed necessary to avert potential danger to other persons in accordance with jurisdictional law, organizational policy, or standards of practice. For example, disclosure about a person threatening violence.

Authorization to collect, access, use, or disclose specified patient health information in accordance with emergency information transfer protocol dictated by jurisdictional law, organization policy, or standards of practice. For example, sharing of health information during disaster response.

Authorization to collect, access, use, or disclose specified patient health information necessary to avert potential public welfare risk in accordance with jurisdictional law, organizational policy, or standards of practice. For example, reporting that a person is a victim of abuse or demonstrating suicidal tendencies.

Authorization to collect, access, use, or disclose specified patient health information for public health, welfare, and safety purposes in accordance with jurisdictional law, organizational policy, or standards of practice. For example, public health reporting of notifiable conditions.

**Definition:**Indicates the set of information types which may be manipulated or referenced, such as for recommending access restrictions.

Description: All patient information.

**Definition:**All information pertaining to a patient's allergy and intolerance records.

Description: All information pertaining to a patient's adverse drug reactions.

**Definition:**All information pertaining to a patient's common observation records (height, weight, blood pressure, temperature, etc.).

**Definition:**All information pertaining to a patient's demographics (such as name, date of birth, gender, address, etc).

**Definition:**All information pertaining to a patient's diagnostic image records (orders & results).

**Definition:**All information pertaining to a patient's vaccination records.

Description: All information pertaining to a patient's lab test records (orders & results)

**Definition:**All information pertaining to a patient's medical condition records.

Description: All information pertaining to a patient's mental health records.

**Definition:**All information pertaining to a patient's professional service records (such as smoking cessation, counseling, medication review, mental health).

**Definition:**All information pertaining to a patient's medication records (orders, dispenses and other active medications).

Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.

Codes representing a grouping of invoice elements (totals, sub-totals), reported through a Payment Advice or a Statement of Financial Activity (SOFA). The code can represent summaries by day, location, payee and other cost elements such as bonus, retroactive adjustment and transaction fees.

Codes representing adjustments to a Payment Advice such as retroactive, clawback, garnishee, etc.

Payment initiated by the payor as the result of adjudicating a submitted invoice that arrived to the payor from an electronic source that did not provide a conformant set of HL7 messages (e.g. web claim submission).

Bonus payments based on performance, volume, etc. as agreed to by the payor.

An amount still owing to the payor but the payment is 0$ and this cannot be settled until a future payment is made.

Fees deducted on behalf of a payee for tuition and continuing education.

Fees deducted on behalf of a payee for charges based on a shorter payment frequency (i.e. next day versus biweekly payments.

Fees deducted on behalf of a payee for charges based on a per-transaction or time-period (e.g. monthly) fee.

Payment is based on a payment intent for a previously submitted Invoice, based on formal adjudication results..

Payment initiated by the payor as the result of adjudicating a paper (original, may have been faxed) invoice.

An amount that was owed to the payor as indicated, by a carry forward adjusment, in a previous payment advice

Professional association fee that is collected by the payor from the practitioner/provider on behalf of the association

Retroactive adjustment such as fee rate adjustment due to contract negotiations.

Bonus payments based on performance, volume, etc. as agreed to by the payor.

Fees deducted on behalf of a payee for charges based on a per-transaction or time-period (e.g. monthly) fee.

Codes representing adjustments to a Payment Advice such as retroactive, clawback, garnishee, etc.

Codes representing a grouping of invoice elements (totals, sub-totals), reported through a Payment Advice or a Statement of Financial Activity (SOFA). The code can represent summaries by day, location, payee, etc.

Transaction counts and value totals by invoice type (e.g. RXDINV - Pharmacy Dispense)

Transaction counts and value totals by each instance of an invoice payee.

Transaction counts and value totals by each instance of an invoice payor.

Transaction counts and value totals by each instance of a messaging application on a single processor. It is a registered identifier known to the receivers.

Codes representing a service or product that is being invoiced (billed). The code can represent such concepts as "office visit", "drug X", "wheelchair" and other billable items such as taxes, service charges and discounts.

An identifying data string for healthcare products.

**Description:**United Nations Standard Products and Services Classification, managed by Uniform Code Council (UCC): www.unspsc.org

An identifying data string for A substance used as a medication or in the preparation of medication.

**Description:**Global Trade Item Number is an identifier for trade items developed by GS1 (comprising the former EAN International and Uniform Code Council).

**Description:**Universal Product Code is one of a wide variety of bar code languages widely used in the United States and Canada for items in stores.

The detail item codes to identify charges or changes to the total billing of a claim due to insurance rules and payments.

The billable item codes to identify adjudicator specified components to the total billing of a claim.

That portion of the eligible charges which a covered party must pay for each service and/or product. It is a percentage of the eligible amount for the service/product that is typically charged after the covered party has met the policy deductible. This amount represents the covered party's coinsurance that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.

That portion of the eligible charges which a covered party must pay for each service and/or product. It is a defined amount per service/product of the eligible amount for the service/product. This amount represents the covered party's copayment that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.

That portion of the eligible charges which a covered party must pay in a particular period (e.g. annual) before the benefits are payable by the adjudicator. This amount represents the covered party's deductible that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.

The guarantor, who may be the patient, pays the entire charge for a service. Reasons for such action may include: there is no insurance coverage for the service (e.g. cosmetic surgery); the patient wishes to self-pay for the service; or the insurer denies payment for the service due to contractual provisions such as the need for prior authorization.

That total amount of the eligible charges which a covered party must periodically pay for services and/or products prior to the Medicaid program providing any coverage. This amount represents the covered party's spend down that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results

The covered party pays a percentage of the cost of covered services.

The billable item codes to identify modifications to a billable item charge. As for example after hours increase in the office visit fee.

Premium paid on service fees in compensation for practicing outside of normal working hours.

Premium paid on service fees in compensation for practicing in a remote location.

Premium paid on service fees in compensation for practicing at a location other than normal working location.

The billable item codes to identify provider supplied charges or changes to the total billing of a claim.

A charge to compensate the provider when a patient cancels an appointment with insufficient time for the provider to make another appointment with another patient.

A reduction in the amount charged as a percentage of the amount. For example a 5% discount for volume purchase.

A premium on a service fee is requested because, due to extenuating circumstances, the service took an extraordinary amount of time or supplies.

Under agreement between the parties (payor and provider), a guaranteed level of income is established for the provider over a specific, pre-determined period of time. The normal course of business for the provider is submission of fee-for-service claims. Should the fee-for-service income during the specified period of time be less than the agreed to amount, a top-up amount is paid to the provider equal to the difference between the fee-for-service total and the guaranteed income amount for that period of time. The details of the agreement may specify (or not) a requirement for repayment to the payor in the event that the fee-for-service income exceeds the guaranteed amount.

Anticipated or actual final fee associated with treating a patient.

Anticipated or actual initial fee associated with treating a patient.

An increase in the amount charged as a percentage of the amount. For example, 12% markup on product cost.

A charge to compensate the provider when a patient does not show for an appointment.

Anticipated or actual periodic fee associated with treating a patient. For example, expected billing cycle such as monthly, quarterly. The actual period (e.g. monthly, quarterly) is specified in the unit quantity of the Invoice Element.

The amount for a performance bonus that is being requested from a payor for the performance of certain services (childhood immunizations, influenza immunizations, mammograms, pap smears) on a sliding scale. That is, for 90% of childhood immunizations to a maximum of $2200/yr. An invoice is created at the end of the service period (one year) and a code is submitted indicating the percentage achieved and the dollar amount claimed.

A charge is requested because the patient failed to pick up the item and it took an amount of time to return it to stock for future use.

A charge to cover the cost of travel time and/or cost in conjuction with providing a service or product. It may be charged per kilometer or per hour based on the effective agreement.

Premium paid on service fees in compensation for providing an expedited response to an urgent situation.

The billable item codes to identify modifications to a billable item charge by a tax factor applied to the amount. As for example 7% provincial sales tax.

Federal tax on transactions such as the Goods and Services Tax (GST)

Joint Federal/Provincial Sales Tax

Tax levied by the provincial or state jurisdiction such as Provincial Sales Tax

An identifying data string for medical facility accommodations.

Accommodation type. In Intent mood, represents the accommodation type requested. In Event mood, represents accommodation assigned/used. In Definition mood, represents the available accommodation type.

**Description:**Accommodation type. In Intent mood, represents the accommodation type requested. In Event mood, represents accommodation assigned/used. In Definition mood, represents the available accommodation type.

Accommodations used in the care of diseases that are transmitted through casual contact or respiratory transmission.

Accommodations in which there is only 1 bed.

Uniquely designed and elegantly decorated accommodations with many amenities available for an additional charge.

Accommodations in which there are 2 beds.

Accommodations in which there are 3 or more beds.

**Description:**External value set for accommodation types used in the U.S. Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) including modifiers.

An identifying data string for healthcare procedures.

**Description:**Physicians Current Procedural Terminology (CPT) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Available for the AMA at the address listed for CPT above. These codes are found in Appendix A of CPT 2000 Standard Edition. (CPT 2000 Standard Edition, American Medical Association, Chicago, IL).

**Description:**Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes are procedure identifying codes. HCPCS is Health Care Finance AdministrationaTMs (HFCA) coding scheme to group procedures performed for payment to providers. contains codes for medical equipment, injectable drugs, transportation services, and other services not found in CPT4.

**Description:**International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) are procedure identifying codes. ICD-10-PCS describes the classification of inpatient procedures for statistical purposes.

**Description:**International Classification of Diseases, 9th Revision, Procedure Coding System (ICD-9-PCS) are procedure identifying codes. ICD-9-PCS describes the classification of inpatient procedures for statistical purposes.

An identifying data string for oral health procedure codes, e.g. extract tooth.

Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.

Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for it's immediate children invoice elements.

Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.

Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for it's immediate children invoice elements.

The domain is only specified for an intermediate invoice element group (non-root or non-top level) for an Invoice.

A grouping of invoice element groups and details including the ones specifying the compound ingredients being invoiced. It may also contain generic detail items such as markup.

A grouping of invoice element details including the one specifying an ingredient drug being invoiced. It may also contain generic detail items such as tax or markup.

A grouping of invoice element groups and details including the ones specifying the compound supplies being invoiced. It may also contain generic detail items such as markup.

A grouping of invoice element details including the one specifying the drug being invoiced. It may also contain generic detail items such as markup.

A grouping of invoice element details including the ones specifying the frame fee and the frame dispensing cost that are being invoiced.

A grouping of invoice element details including the ones specifying the lens fee and the lens dispensing cost that are being invoiced.

A grouping of invoice element details including the one specifying the product (good or supply) being invoiced. It may also contain generic detail items such as tax or discount.

Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.

Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for it's immediate children invoice elements.

Codes from this domain reflect the type of Invoice such as Pharmacy Dispense, Clinical Service and Clinical Product. The domain is only specified for the root (top level) invoice element group for an Invoice.

Clinical product invoice where the Invoice Grouping contains one or more billable item and is supported by clinical product(s).

For example, a crutch or a wheelchair.

Clinical product invoice where the Invoice Grouping contains one or more billable item and is supported by clinical product(s).

For example, a crutch or a wheelchair.

Clinical Services Invoice which can be used to describe a single service, multiple services or repeated services.

[1] Single Clinical services invoice where the Invoice Grouping contains one billable item and is supported by one clinical service.

For example, a single service for an office visit or simple clinical procedure (e.g. knee mobilization).

[2] Multiple Clinical services invoice where the Invoice Grouping contains more than one billable item, supported by one or more clinical services. The services can be distinct and over multiple dates, but for the same patient. This type of invoice includes a series of treatments which must be adjudicated together.

For example, an adjustment and ultrasound for a chiropractic session where fees are associated for each of the services and adjudicated (invoiced) together.

[3] Repeated Clinical services invoice where the Invoice Grouping contains one or more billable item, supported by the same clinical service repeated over a period of time.

For example, the same Chiropractic adjustment (service or treatment) delivered on 3 separate occasions over a period of time at the discretion of the provider (e.g. month).

Clinical Services Invoice which can be used to describe a single service, multiple services or repeated services.

[1] Single Clinical services invoice where the Invoice Grouping contains one billable item and is supported by one clinical service.

For example, a single service for an office visit or simple clinical procedure (e.g. knee mobilization).

[2] Multiple Clinical services invoice where the Invoice Grouping contains more than one billable item, supported by one or more clinical services. The services can be distinct and over multiple dates, but for the same patient. This type of invoice includes a series of treatments which must be adjudicated together.

For example, an adjustment and ultrasound for a chiropractic session where fees are associated for each of the services and adjudicated (invoiced) together.

[3] Repeated Clinical services invoice where the Invoice Grouping contains one or more billable item, supported by the same clinical service repeated over a period of time.

For example, the same Chiropractic adjustment (service or treatment) delivered on 3 separate occasions over a period of time at the discretion of the provider (e.g. month).

A clinical Invoice Grouping consisting of one or more services and one or more product. Billing for these service(s) and product(s) are supported by multiple clinical billable events (acts).

All items in the Invoice Grouping must be adjudicated together to be acceptable to the Adjudicator.

For example , a brace (product) invoiced together with the fitting (service).

Invoice Grouping without clinical justification. These will not require identification of participants and associations from a clinical context such as patient and provider.

Examples are interest charges and mileage.

A clinical Invoice Grouping consisting of one or more oral health services. Billing for these service(s) are supported by multiple clinical billable events (acts).

All items in the Invoice Grouping must be adjudicated together to be acceptable to the Adjudicator.

HealthCare facility preferred accommodation invoice.

HealthCare facility preferred accommodation invoice.

Pharmacy dispense invoice for a compound.

Pharmacy dispense invoice for a compound.

Pharmacy dispense invoice not involving a compound

Pharmacy dispense invoice not involving a compound

Clinical services invoice where the Invoice Group contains one billable item for multiple clinical services in one or more sessions.

Vision dispense invoice for up to 2 lens (left and right), frame and optional discount. Eye exams are invoiced as a clinical service invoice.

Identifies the different types of summary information that can be reported by queries dealing with Statement of Financial Activity (SOFA). The summary information is generally used to help resolve balance discrepancies between providers and payors.

Total counts and total net amounts adjudicated for all Invoice Groupings that were adjudicated within a time period based on the adjudication date of the Invoice Grouping.

Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.

Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.

Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.

Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.

Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.

Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.

Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.

Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.

Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently nullified in the specified period and submitted electronically.

Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently nullified in the specified period and submitted electronically.