{ "resourceType" : "CodeSystem", "id" : "plan-benefits-cost-qualifier", "text" : { "status" : "generated", "div" : "

Generated Narrative: CodeSystem plan-benefits-cost-qualifier

This case-sensitive code system https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier defines the following codes:

CodeDisplayDefinition
tier-1 In network, tier 1The plan's first in-network tier. Used only for a plan with two in-network tiers.
tier-2 In network, tier 2The plan's second in-network tier, which has its own costs, deductible and out-of-pocket maximum.
point-of-service Point of serviceCare from providers outside an HMO's network under the plan's point-of-service option. Written with applicability out-of-network.
per-visit Per visitThe cost is charged for each visit.
per-day Per dayThe cost is charged for each day of a stay. Where a day range is given, the cost applies to those days of the stay.
per-stay Per stayThe cost is charged once for each stay.
one-price-both-networks One price in and out of networkThe plan files one price for this service for both in network and out of network, so the same price appears under both.
after-deductible After deductibleCMS's file says the cost applies after deductible.
with-deductible With deductibleCMS's file says the cost applies with deductible. CMS lists this apart from "after deductible", and haau3 does not interpret either.
counts-toward-maximum Counts toward the out-of-pocket maximumThe plan files that this service counts toward the out-of-pocket maximum for this network.
excluded-from-maximum Does not count toward the out-of-pocket maximumThe plan files that this service does not count toward the out-of-pocket maximum for this network.
no-copay-or-coinsurance-filed No copay or coinsuranceThe plan answered No both to a copay and to a coinsurance for this service, which means the member pays $0.
varies-by-hospital-tier Varies by hospital tierThe plan charges different amounts at different tiers of hospitals. The cost given is the plan's tier 1.
" }, "url" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier", "version" : "1.0.0", "name" : "PlanBenefitsCostQualifierCS", "title" : "Plan Benefits Cost Qualifier", "status" : "active", "experimental" : false, "date" : "2026-10-14T18:01:46+00:00", "publisher" : "haau3", "contact" : [{ "name" : "haau3", "telecom" : [{ "system" : "url", "value" : "https://haau3.com" }, { "system" : "email", "value" : "hello@haau3.com" }] }], "description" : "Facts that describe a Plan Benefits cost entry: which in-network tier it is, how it is charged, and how it relates to the deductible and the out-of-pocket maximum. haau3 publishes these until the SBC guide codes them.", "jurisdiction" : [{ "coding" : [{ "system" : "urn:iso:std:iso:3166", "code" : "US", "display" : "United States of America" }] }], "caseSensitive" : true, "content" : "complete", "count" : 13, "concept" : [{ "code" : "tier-1", "display" : "In network, tier 1", "definition" : "The plan's first in-network tier. Used only for a plan with two in-network tiers." }, { "code" : "tier-2", "display" : "In network, tier 2", "definition" : "The plan's second in-network tier, which has its own costs, deductible and out-of-pocket maximum." }, { "code" : "point-of-service", "display" : "Point of service", "definition" : "Care from providers outside an HMO's network under the plan's point-of-service option. Written with applicability out-of-network." }, { "code" : "per-visit", "display" : "Per visit", "definition" : "The cost is charged for each visit." }, { "code" : "per-day", "display" : "Per day", "definition" : "The cost is charged for each day of a stay. Where a day range is given, the cost applies to those days of the stay." }, { "code" : "per-stay", "display" : "Per stay", "definition" : "The cost is charged once for each stay." }, { "code" : "one-price-both-networks", "display" : "One price in and out of network", "definition" : "The plan files one price for this service for both in network and out of network, so the same price appears under both." }, { "code" : "after-deductible", "display" : "After deductible", "definition" : "CMS's file says the cost applies after deductible." }, { "code" : "with-deductible", "display" : "With deductible", "definition" : "CMS's file says the cost applies with deductible. CMS lists this apart from \"after deductible\", and haau3 does not interpret either." }, { "code" : "counts-toward-maximum", "display" : "Counts toward the out-of-pocket maximum", "definition" : "The plan files that this service counts toward the out-of-pocket maximum for this network." }, { "code" : "excluded-from-maximum", "display" : "Does not count toward the out-of-pocket maximum", "definition" : "The plan files that this service does not count toward the out-of-pocket maximum for this network." }, { "code" : "no-copay-or-coinsurance-filed", "display" : "No copay or coinsurance", "definition" : "The plan answered No both to a copay and to a coinsurance for this service, which means the member pays $0." }, { "code" : "varies-by-hospital-tier", "display" : "Varies by hospital tier", "definition" : "The plan charges different amounts at different tiers of hospitals. The cost given is the plan's tier 1." }] }