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Generated Narrative: CodeSystem claim-adjudication-basis-categories

Last updated: 2026-06-12 00:00:00+0000

Profile: Shareable CodeSystem

This case-sensitive code system http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories defines the following codes:

Code | Display | Definition
billing-network-status | Billing Provider Network Status | Indicates the billing provider's participation status with the payer's network or contractual arrangements used in the adjudication of the claim, including determination of applicable pricing, coverage, or payment rules.
rendering-network-status | Rendering Provider Network Status | Indicates the rendering provider's participation status with the payer's network or contractual arrangements used in the adjudication of the claim, including determination of applicable pricing, coverage, or payment rules.
benefit-payment-status | Benefit Payment Status | Indicates the network or contractual status of the service or product (in or out of network) in context to its provisioning used in the adjudication of the claim, including determination of applicable pricing, coverage, or payment rules
adjustment-reason | Adjustment Reason | Indicates that a policy, contract, or administratively defined adjustment rationale was applied during claim adjudication, affecting the allowed amount, payment amount, or member liability.
medical-management-requirement | Medical Management Requirements | Indicates that compliance with a medical management requirement (such as prior authorization, referral, step therapy, or utilization review) was a factor in the adjudication of the claim.

# description
Categories of contractual, policy, benefit, or administrative bases used by a payer when adjudicating a healthcare claim and determining the allowed, paid, or adjusted amounts. These codes include categories that describe why a claim line or claim total was adjudicated as it was, rather than the result of the adjudication.

# copyright
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

# concept[].definition
Indicates the billing provider's participation status with the payer's network or contractual arrangements used in the adjudication of the claim, including determination of applicable pricing, coverage, or payment rules.

# concept[].definition
Indicates the rendering provider's participation status with the payer's network or contractual arrangements used in the adjudication of the claim, including determination of applicable pricing, coverage, or payment rules.

# concept[].definition
Indicates the network or contractual status of the service or product (in or out of network) in context to its provisioning used in the adjudication of the claim, including determination of applicable pricing, coverage, or payment rules

# concept[].definition
Indicates that a policy, contract, or administratively defined adjustment rationale was applied during claim adjudication, affecting the allowed amount, payment amount, or member liability.

# concept[].definition
Indicates that compliance with a medical management requirement (such as prior authorization, referral, step therapy, or utilization review) was a factor in the adjudication of the claim.