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TX: ValueSet claim-adjudication-basis-categories

Properties

Profile http://hl7.org/fhir/StructureDefinition/shareablevalueset
Last updated June 12, 2026 at 12:00:00 AM UTC
Defining URL http://terminology.hl7.org/ValueSet/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.html
EXT_FMM_LEVEL 1

Logical Definition

This value set includes codes based on the following rules:

Expansion

This ValueSet depends on the following items:

Code System Display
billing-network-status http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories Billing Provider Network Status
rendering-network-status http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories Rendering Provider Network Status
benefit-payment-status http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories Benefit Payment Status
adjustment-reason http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories Adjustment Reason
medical-management-requirement http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories Medical Management Requirements