Variable: Adjudication
Adjudication Information
Description:
This code system includes a selection of Adjudication Value Codes which convey the payers assessment of the item provided in the claim under the terms of the patient’s insurance coverage.
Values
This variable is coded, and will contain one of the following values.
| Value | Description |
|---|---|
| CLM_LINE_NCVRD_CHRG_AMT | Non-Covered Charge Amount |
| CLM_LINE_ALOWD_CHRG_AMT | Line Allowed Charge Amount |
| CLM_LINE_SBMT_CHRG_AMT | Line Submitted Charge Amount |
| CLM_LINE_PRVDR_PMT_AMT | Line Provider Payment Amount |
| CLM_LINE_BENE_PMT_AMT | Line Paid By Beneficiary Amount |
| CLM_LINE_BENE_PD_AMT | Payment Amount to Beneficiary |
| CLM_LINE_CVRD_PD_AMT | Payment Amount |
| CLM_LINE_BLOOD_DDCTBL_AMT | Blood Deductible Amount |
| CLM_LINE_MDCR_DDCTBL_AMT | Cash Deductible Amount |
| CLM_LINE_INSTNL_ADJSTD_AMT | Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount |
| CLM_LINE_INSTNL_RDCD_AMT | Revenue Center Reduced Coinsurance Amount |
| CLM_LINE_INSTNL_MSP1_PD_AMT | Revenue Center 1st MSP Paid Amount |
| CLM_LINE_INSTNL_MSP2_PD_AMT | Revenue Center 2nd MSP Paid Amount |
| CLM_LINE_INSTNL_RATE_AMT | Revenue Center Rate Amount |
| CLM_SBMT_CHRG_AMT | Total Charge Amount |
| CLM_LINE_GRS_ABOVE_THRSHLD_AMT | Gross Drug Cost Above Out Of Pocket Threshold |
| CLM_LINE_GRS_BLW_THRSHLD_AMT | Gross Drug Cost Below Out Of Pocket Threshold |
| CLM_LINE_LIS_AMT | Low Income Cost Sharing Subsidy Amount |
| CLM_LINE_TROOP_TOT_AMT | Other True Out Of Pocket Paid Amount |
| CLM_LINE_PLRO_AMT | Patient Liability Reduction Other Paid Amount |
| CLM_RPTD_MFTR_DSCNT_AMT | Gap Discount Amount |
| CLM_LINE_INGRDNT_CST_AMT | Ingredient Cost Amount |
| CLM_LINE_SRVC_CST_AMT | Dispensing Fee |
| CLM_LINE_SLS_TAX_AMT | Sales Tax Amount |
| CLM_LINE_VCCN_ADMIN_FEE_AMT | Vaccination Administration Fee |
| CLM_PRVDR_PMT_AMT | Provider Payment Amount |
| CLM_BENE_PMT_AMT | Paid By Beneficiary Amount |
| CLM_ALOWD_CHRG_AMT | Allowed Charge Amount |
| CLM_LINE_MDCR_COINSRNC_AMT | Coinsurance Amount |
| CLM_MDCR_PRFNL_PRMRY_PYR_AMT | Primary Payer Paid Amount |
| CLM_BENE_PRMRY_PYR_PD_AMT | Line Primary Payer Paid Amount |
| CLM_LINE_PRFNL_DME_PRICE_AMT | Purchase Price Amount |
| CLM_LINE_DMERC_SCRN_SVGS_AMT | Screen Savings Amount |
| CLM_BENE_PD_AMT | Amount Paid To Beneficiary Amount |
| CLM_OPRTNL_DSPRTNT_AMT | Operating Disproportionate Share Amount |
| CLM_OPRTNL_IME_AMT | Operating Indirect Medical Education Amount |
| CLM_BLOOD_LBLTY_AMT | Beneficiary Blood Deductible Liability Amount |
| CLM_MDCR_DDCTBL_AMT | Beneficiary Deductible Amount |
| CLM_NCVRD_CHRG_AMT | Inpatient(or other Part A) Non-covered Charge Amount |
| CLM_MDCR_COINSRNC_AMT | Beneficiary Coinsurance Liability Amount |
| CLM_MDCR_IP_LRD_USE_CNT | Beneficiary Medicare Lifetime Reserve Days (LRD) Used Count |
| CLM_INSTNL_MDCR_COINS_DAY_CNT | Beneficiary Total Coinsurance Days Count |
| CLM_INSTNL_NCVRD_DAY_CNT | Claim Medicare Non Utilization Days Count |
| CLM_INSTNL_PER_DIEM_AMT | Claim Pass Thru Per Diem Amount |
| CLM_INSTNL_CVRD_DAY_CNT | Claim Medicare Utilization Day Count |
| CLM_MDCR_IP_PPS_DSPRPRTNT_AMT | Claim PPS Capital Disproportionate Share Amount |
| CLM_MDCR_IP_PPS_EXCPTN_AMT | Claim PPS Capital Exception Amount |
| CLM_MDCR_IP_PPS_CPTL_FSP_AMT | Claim PPS Capital Federal Specific Portion (FSP) Amount |
| CLM_MDCR_IP_PPS_CPTL_IME_AMT | Claim PPS Capital Indirect Medical Education (IME) Amount |
| CLM_MDCR_IP_PPS_OUTLIER_AMT | Claim PPS Capital Outlier Amount |
| CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT | Claim PPS Old Capital Hold Harmless Amount |
| CLM_MDCR_IP_PPS_CPTL_TOT_AMT | Claim Total PPS Capital Amount |
| CLM_MDCR_INSTNL_PRMRY_PYR_AMT | Primary Payer (if not Medicare) Claim Paid Amount |
| CLM_INSTNL_PRFNL_AMT | Professional Component Charge Amount |
| CLM_INSTNL_DRG_OUTLIER_AMT | DRG Outlier Approved Payment Amount |
| CLM_MDCR_IP_BENE_DDCTBL_AMT | Beneficiary Inpatient (or other Part A) Deductible Amount |
| CLM_HIPPS_UNCOMPD_CARE_AMT | Claim Uncompensated Care Payment Amount |
| CLM_MDCR_INSTNL_BENE_PD_AMT | Institutional Paid to Beneficiary Amount |
| CLM_MDCR_HOSPC_PRD_CNT | Hospice Period Count |
| CLM_MDCR_HHA_TOT_VISIT_CNT | Claim HHA Visit Count |
| CLM_MDCR_IP_PPS_DRG_WT_NUM | PPS DRG Weight Number |
| CLM_BENE_INTRST_PD_AMT | Beneficiary Interest Paid Amount |
| CLM_BENE_PMT_COINSRNC_AMT | Beneficiary Coinsurance Amount |
| CLM_BLOOD_CHRG_AMT | Blood Charge Amount |
| CLM_BLOOD_NCVRD_CHRG_AMT | Blood Noncovered Charge Amount |
| CLM_COB_PTNT_RESP_AMT | Coordination of Benefits Patient Responsibility Amount |
| CLM_OTHR_TP_PD_AMT | Other Third Party Payer Paid Amount |
| CLM_PRVDR_INTRST_PD_AMT | Provider Interest Paid Amount |
| CLM_PRVDR_OTAF_AMT | Provider Obligation To Accept as Full Amount |
| CLM_PRVDR_RMNG_DUE_AMT | Remaining Amount to Provider |
| CLM_TOT_CNTRCTL_AMT | Total Contractual Amount Discrepancy |
| CLM_FINL_STDZD_PYMT_AMT | Standardized Payment Amount |
| CLM_HAC_RDCTN_PYMT_AMT | Hospital Acquired Condition Reduction Amount |
| CLM_HIPPS_MODEL_BNDLD_PMT_AMT | Blended Payment Amount |
| CLM_HIPPS_READMSN_RDCTN_AMT | Readmission Reduction Amount |
| CLM_HIPPS_VBP_AMT | HIPPS Value Based Purchasing Amount |
| CLM_INSTNL_LOW_VOL_PMT_AMT | Low Volume Payment Amount |
| CLM_MDCR_IP_1ST_YR_RATE_AMT | First Year Rate Amount |
| CLM_MDCR_IP_SCND_YR_RATE_AMT | Second Year Rate Amount |
| CLM_PPS_MD_WVR_STDZD_VAL_AMT | Maryland Waiver Standardized Amount |
| CLM_SITE_NTRL_CST_BSD_PYMT_AMT | Site-Neutral Cost-Based Payment Amount |
| CLM_SITE_NTRL_IP_PPS_PYMT_AMT | Site-Neutral IPPS Payment Amount |
| CLM_SS_OUTLIER_STD_PYMT_AMT | Short Stay Outlier Payment Amount |
| CLM_PRVDR_ACNT_RCVBL_OFST_AMT | Provider Offset Amount |
| CLM_LINE_NCVRD_PD_AMT | Amount Paid for Noncovered Product or Service |
| CLM_LINE_OTAF_AMT | Provider Obligation To Accept as Full Amount |
| CLM_LINE_OTHR_TP_PD_AMT | Other Third Party Paid Amount |
| CLM_LINE_ADD_ON_PYMT_AMT | Add On Payment Amount |
| CLM_LINE_NON_EHR_RDCTN_AMT | Non-EHR Reduction Amount |
| CLM_REV_CNTR_TDAPA_AMT | Transitional Drug Add-On Payment Adjustment |
| CLM_LINE_CARR_CLNCL_CHRG_AMT | Carrier Clinical Charge Amount |
| CLM_LINE_CARR_PSYCH_OT_LMT_AMT | Therapy Amount Applied to Limit |
| CLM_LINE_PRFNL_INTRST_AMT | Professional Interest Amount |
| CLM_MDCR_PRMRY_PYR_ALOWD_AMT | Line Primary Payer Allowed Amount |
| CLM_CMS_CALCD_MFTR_DSCNT_AMT | CMS Calculated Manufacturer Discount Amount |
| CLM_LINE_REBT_PASSTHRU_POS_AMT | Rebate Passthrough POS Amount |
| CLM_PHRMCY_PRICE_DSCNT_AT_POS_AMT | Pharmacy price discount |
| CLM_LINE_GRS_CVRD_CST_TOT_AMT | Claim Line Gross Covered Cost Amount |
| CLM_LINE_RPTD_GAP_DSCNT_AMT | Claim Line Reported Gap Discount Amount |
| TOT_RX_CST_AMT | Total RX Cost Amount |