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TX: CodeSystem claim-adjudication-basis-categories

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:

CodeDisplayDefinition
billing-network-status Billing Provider Network StatusIndicates 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 StatusIndicates 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 StatusIndicates 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 ReasonIndicates 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 RequirementsIndicates 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.