haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Active as of 2026-10-14 |
{
"resourceType" : "CodeSystem",
"id" : "plan-benefits-cost-qualifier",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem plan-benefits-cost-qualifier</b></p><a name=\"plan-benefits-cost-qualifier\"> </a><a name=\"hcplan-benefits-cost-qualifier\"> </a><p>This case-sensitive code system <code>https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">tier-1<a name=\"plan-benefits-cost-qualifier-tier-1\"> </a></td><td>In network, tier 1</td><td>The plan's first in-network tier. Used only for a plan with two in-network tiers.</td></tr><tr><td style=\"white-space:nowrap\">tier-2<a name=\"plan-benefits-cost-qualifier-tier-2\"> </a></td><td>In network, tier 2</td><td>The plan's second in-network tier, which has its own costs, deductible and out-of-pocket maximum.</td></tr><tr><td style=\"white-space:nowrap\">point-of-service<a name=\"plan-benefits-cost-qualifier-point-of-service\"> </a></td><td>Point of service</td><td>Care from providers outside an HMO's network under the plan's point-of-service option. Written with applicability out-of-network.</td></tr><tr><td style=\"white-space:nowrap\">per-visit<a name=\"plan-benefits-cost-qualifier-per-visit\"> </a></td><td>Per visit</td><td>The cost is charged for each visit.</td></tr><tr><td style=\"white-space:nowrap\">per-day<a name=\"plan-benefits-cost-qualifier-per-day\"> </a></td><td>Per day</td><td>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.</td></tr><tr><td style=\"white-space:nowrap\">per-stay<a name=\"plan-benefits-cost-qualifier-per-stay\"> </a></td><td>Per stay</td><td>The cost is charged once for each stay.</td></tr><tr><td style=\"white-space:nowrap\">one-price-both-networks<a name=\"plan-benefits-cost-qualifier-one-price-both-networks\"> </a></td><td>One price in and out of network</td><td>The plan files one price for this service for both in network and out of network, so the same price appears under both.</td></tr><tr><td style=\"white-space:nowrap\">after-deductible<a name=\"plan-benefits-cost-qualifier-after-deductible\"> </a></td><td>After deductible</td><td>CMS's file says the cost applies after deductible.</td></tr><tr><td style=\"white-space:nowrap\">with-deductible<a name=\"plan-benefits-cost-qualifier-with-deductible\"> </a></td><td>With deductible</td><td>CMS's file says the cost applies with deductible. CMS lists this apart from "after deductible", and haau3 does not interpret either.</td></tr><tr><td style=\"white-space:nowrap\">counts-toward-maximum<a name=\"plan-benefits-cost-qualifier-counts-toward-maximum\"> </a></td><td>Counts toward the out-of-pocket maximum</td><td>The plan files that this service counts toward the out-of-pocket maximum for this network.</td></tr><tr><td style=\"white-space:nowrap\">excluded-from-maximum<a name=\"plan-benefits-cost-qualifier-excluded-from-maximum\"> </a></td><td>Does not count toward the out-of-pocket maximum</td><td>The plan files that this service does not count toward the out-of-pocket maximum for this network.</td></tr><tr><td style=\"white-space:nowrap\">no-copay-or-coinsurance-filed<a name=\"plan-benefits-cost-qualifier-no-copay-or-coinsurance-filed\"> </a></td><td>No copay or coinsurance</td><td>The plan answered No both to a copay and to a coinsurance for this service, which means the member pays $0.</td></tr><tr><td style=\"white-space:nowrap\">varies-by-hospital-tier<a name=\"plan-benefits-cost-qualifier-varies-by-hospital-tier\"> </a></td><td>Varies by hospital tier</td><td>The plan charges different amounts at different tiers of hospitals. The cost given is the plan's tier 1.</td></tr></table></div>"
},
"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."
}
]
}