HL7 Terminology (THO)
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This page is part of the HL7 Terminology (v7.3.0: Release) based on FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions

CodeSystem: Claim Adjudication Basis Categories

Official URL: http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories Version: 1.0.0
Active as of 2026-07-27 Maturity Level: 1 Responsible: Health Level Seven International Computable Name: ClaimAdjudicationBasisCategories
Other Identifiers: OID:2.16.840.1.113883.5.178

Copyright/Legal: 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

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.

This Code system is referenced in the definition of the following value sets:

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 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 of the above table(s).

History

DateActionAuthorCustodianComment
2026-07-24createCorey SpearsFMCreate a new CodeSystem: Claim Adjudication Basis Category Codes and associated ValueSet including all codes from this CodeSystem; up-818