HL7 Terminology (THO)
7.1.0 - Publication International flag

This page is part of the HL7 Terminology (v7.1.0: Release) based on FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. 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
Responsible: Health Level Seven International Computable Name: ActInvoiceDetailGenericAdjudicatorCode
Other Identifiers: 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.html

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)

Language: en

This value set includes codes based on the following rules:

This value set excludes codes based on the following rules:

 

Expansion

Expansion performed internally based on codesystem ActCode v10.0.0 (CodeSystem)

This value set contains 6 concepts

SystemCodeDisplay (en)InactiveDefinitionJSONXML
http://terminology.hl7.org/CodeSystem/v3-ActCode  COINcoinsurance

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.

http://terminology.hl7.org/CodeSystem/v3-ActCode  COPAYMENTpatient 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.

http://terminology.hl7.org/CodeSystem/v3-ActCode  DEDUCTIBLEdeductible

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.

http://terminology.hl7.org/CodeSystem/v3-ActCode  PAYpayment

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.

http://terminology.hl7.org/CodeSystem/v3-ActCode  SPENDspend 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

http://terminology.hl7.org/CodeSystem/v3-ActCode  COINSco-insuranceinactive

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


Description of the above table(s).


History

DateActionCustodianAuthorComment
2023-11-14reviseTSMGMarc DuteauAdd standard copyright and contact to internal content; up-476
2022-10-18reviseTSMGMarc DuteauFixing missing metadata; up-349
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26