**Description:**Codes used to specify reasons or criteria relating to coverage provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, including criteria for eligibility, coverage limitations, coverage maximums, or financial participation required of covered parties.

Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam.

Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status.

Identifies the reason or rational for why a person is not eligibile for benefits under an insurance policy.

Examples are client deceased & adopted client has been given a new policy identifier.

When a client has no contact with the health system for an extended period, coverage is suspended. Client will be reinstated to original start date upon proof of identification, residency etc.

Example: Coverage may be suspended during a strike situation, when employer benefits for employees are not covered (i.e. not in effect).

Client deceased.

Client was registered in error.

Definition: Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam.

Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status.

A person becomes eligible for a program based on age.

Example: In the U.S., a person who is 65 years of age or older is eligible for Medicare.

A person becomes eligible for insurance or a program because of crime related health condition or injury.

Example: A person is a claimant under the U.S. Crime Victims Compensation program.

A person becomes a claimant under a disability income insurance policy or a disability rehabilitation program because of a health condition or injury which limits the person's ability to earn an income or function without institutionalization.

A person becomes eligible for insurance provided as an employment benefit based on employment status.

A person becomes eligible for a program based on financial criteria.

Example: A person whose family income is below a financial threshold for eligibility for Medicaid or SCHIP.

A person becomes eligible for a program because of a qualifying health condition or injury.

Examples: A person is determined to have a qualifying health conditions include pregnancy, HIV/AIDs, tuberculosis, end stage renal disease, breast or cervical cancer, or other condition requiring specialized health services, hospice, institutional or community based care provided under a program

A person becomes eligible for a program based on more than one criterion.

Examples: In the U.S., a child whose familiy income meets Medicaid financial thresholds and whose age is less than 18 is eligible for the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT). A person whose family income meets Medicaid financial thresholds and whose age is 65 years or older is eligible for Medicaid and Medicare, and are referred to as dual eligibles.

A person becomes a claimant under a property and casualty insurance policy because of a related health condition or injury resulting from a circumstance covered under the terms of the policy.

Example: A person is a claimant under a homeowners insurance policy because of an injury sustained on the policyholderaTMs premises.

A person becomes eligible for a program based on statutory criteria.

Examples: A person is a member of an indigenous group, a veteran of military service, or in the U.S., a recipient of adoption assistance and foster care under Title IV-E of the Social Security.

A person becomes a claimant under a motor vehicle accident insurance because of a motor vehicle accident related health condition or injury.

A person becomes eligible for insurance or a program because of a work related health condition or injury.

Example: A person is a claimant under the U.S. Black Lung Program.

**Description:**Identifies the reason or rationale for coverage of a service or product based on characteristics of the provider, e.g., contractual relationship to payor, such as in or out-of-network; relationship of the covered party to the provider.

**Example:**In closed managed care plan, a covered party is assigned a primary care provider who provides primary care services and authorizes referrals and ancillary and non-primary care services.

**Description:**Identifies the reason or rationale for coverage of a service or product based on clinical efficacy criteria or practices prescribed by the payor.

Definition: Identifies the reason or rationale for coverage of a service or product based on coverage exclusions related to the risk of adverse selection by covered parties.

**Description:**Identifies the reason or rationale for coverage of a service or product based on financial participation responsibilities of the covered party.

**Description:**Identifies the reason or rationale for limitations on the coverage of a service or product based on coverage contract provisions.

**Example:**The maximum cost per unit; or the maximum number of units per period, which is typically the policy or program effective time.