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TX: CodeSystem claim-adjudication-basis-categories

Properties

Profile http://hl7.org/fhir/StructureDefinition/shareablecodesystem
Last updated: June 12, 2026 at 12:00:00 AM UTC
Defining URL http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories
Version 1.0.0
Name ClaimAdjudicationBasisCategories
Title Claim Adjudication Basis Categories
Status active
Definition

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.
Publisher Health Level Seven International
Committee fm
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
EXT_FMM_LEVEL 1
Source hl7.terminology.r4#7.3.0
Value Set Claim Adjudication Basis Categories

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.