HL7 Terminology (THO)
7.3.0 - Publication
HL7 Terminology (THO)
7.3.0 - Publication
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
| Official URL: http://terminology.hl7.org/ValueSet/claim-adjudication-basis-categories | Version: 1.0.0 | ||||
| Active as of 2026-06-12 | Maturity Level: 1 | Responsible: Health Level Seven International | Computable Name: ClaimAdjudicationBasisCategories | ||
| Other Identifiers: OID:2.16.840.1.113883.11.21041 | |||||
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.html |
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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.
References
This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)
Last updated: 2026-06-12 00:00:00+0000
Profile: Shareable ValueSet
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories version 📦1.0.0
Expansion performed internally based on codesystem Claim Adjudication Basis Categories v1.0.0 (CodeSystem)
This value set contains 5 concepts
| System | Code | Display (en) | Definition | JSON | XML |
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories | 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. | ||
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories | 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. | ||
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories | 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 | ||
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories | 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. | ||
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories | 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
| Date | Action | Custodian | Author | Comment |
| 2026-07-24 | create | FM | Corey Spears | Create a new CodeSystem: Claim Adjudication Basis Category Codes and associated ValueSet including all codes from this CodeSystem; up-818 |
IG © 2020+ HL7 International - Vocabulary Work Group.
Package hl7.terminology#7.3.0 based on FHIR 5.0.0.
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2026-07-27
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