HL7 Terminology (THO)
5.4.0 - Publication International flag

This page is part of the HL7 Terminology (v5.4.0: Release) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

ValueSet: ActInvoiceDetailGenericAdjudicatorCode

Official URL: http://terminology.hl7.org/ValueSet/v3-ActInvoiceDetailGenericAdjudicatorCode Version: 3.0.0
Active as of 2014-03-26 Responsible: Health Level Seven International Computable Name: ActInvoiceDetailGenericAdjudicatorCode
Other Identifiers: id: Uniform Resource Identifier (URI)#urn:oid:2.16.840.1.113883.1.11.19411

Copyright/Legal: This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license

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

References

This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

Logical Definition (CLD)

This value set includes codes based on the following rules:

This value set excludes codes based on the following rules:

 

Expansion

This value set contains 6 concepts

Expansion based on codesystem ActCode v9.0.0 (CodeSystem)

CodeSystemDisplayInactiveDefinition
  COINhttp://terminology.hl7.org/CodeSystem/v3-ActCodecoinsurance

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.

  COPAYMENThttp://terminology.hl7.org/CodeSystem/v3-ActCodepatient co-pay

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.

  DEDUCTIBLEhttp://terminology.hl7.org/CodeSystem/v3-ActCodedeductible

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.

  PAYhttp://terminology.hl7.org/CodeSystem/v3-ActCodepayment

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.

  SPENDhttp://terminology.hl7.org/CodeSystem/v3-ActCodespend down

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

  COINShttp://terminology.hl7.org/CodeSystem/v3-ActCodeco-insuranceinactive

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

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code

History

DateActionAuthorCustodianComment
2023-11-14reviseMarc DuteauTSMGAdd standard copyright and contact to internal content; up-476
2022-10-18reviseMarc DuteauTSMGFixing missing metadata; up-349
2020-05-06reviseTed KleinVocabulary WGMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26reviseVocabulary (Woody Beeler) (no record of original request)2014T1_2014-03-26_001283 (RIM release ID)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26