HL7 Terminology (THO)
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HL7 Terminology (THO), published by HL7 International - Vocabulary Work Group. This guide is not an authorized publication; it is the continuous build for version 7.3.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/UTG/ and changes regularly. See the Directory of published versions

ValueSet: Claim Adjudication Basis Categories

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

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)

Logical Definition (CLD)

Last updated: 2026-06-12 00:00:00+0000

Profile: Shareable ValueSet

 

Expansion

Expansion performed internally based on codesystem Claim Adjudication Basis Categories v1.0.0 (CodeSystem)

This value set contains 5 concepts

SystemCodeDisplay (en)DefinitionJSONXML
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories  billing-network-statusBilling 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.
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories  rendering-network-statusRendering 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.
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories  benefit-payment-statusBenefit 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
http://terminology.hl7.org/CodeSystem/claim-adjudication-basis-categories  adjustment-reasonAdjustment ReasonIndicates 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-requirementMedical 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.

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