FHIR Implementation Guide for HCX
0.0.1 - CI Build
FHIR Implementation Guide for HCX
0.0.1 - CI Build
FHIR Implementation Guide for HCX - Local Development build (v0.0.1). See the Directory of published versions
<ValueSet xmlns="http://hl7.org/fhir">
<id value="claim-denial-codes"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>This value set contains 65 concepts</p><p>All codes from system <code>http://hcp.org/codes/denial-code</code></p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-ELIG-001"> </a>ELIG-001</td><td>Patient is not a covered member</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-ELIG-005"> </a>ELIG-005</td><td>Services performed after the last date of coverage</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-ELIG-006"> </a>ELIG-006</td><td>Services performed prior to the effective date of coverage</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-ELIG-007"> </a>ELIG-007</td><td>Services performed by a non-network provider</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-001"> </a>AUTH-001</td><td>Prior approval is required and was not obtained</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-003"> </a>AUTH-003</td><td>PriorAuthorizationNumber is invalid</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-004"> </a>AUTH-004</td><td>Service(s) is (are) performed outside authorization validity date</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-005"> </a>AUTH-005</td><td>Claim information is inconsistent with pre-certified/authorized services</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-006"> </a>AUTH-006</td><td>Alert drug - drug interaction or drug is contra-indicated</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-007"> </a>AUTH-007</td><td>Drug duplicate therapy</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-008"> </a>AUTH-008</td><td>Inappropriate drug dose</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-009"> </a>AUTH-009</td><td>Prescription out of date</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-010"> </a>AUTH-010</td><td>Authorization request overlaps or is within the period of another paid claim or approved authorization</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-011"> </a>AUTH-011</td><td>Waiting period on pre-existing / specific conditions</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-AUTH-012"> </a>AUTH-012</td><td>Request for information</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-BENX-002"> </a>BENX-002</td><td>Benefit maximum for this time period or occurrence has been reached</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-BENX-005"> </a>BENX-005</td><td>Annual limit/sublimit amount exceeded</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-007"> </a>CLAI-007</td><td>Claim is a work-related injury/illness and thus the liability of the employer</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-008"> </a>CLAI-008</td><td>Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-009"> </a>CLAI-009</td><td>Date of birth follows the date of service</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-010"> </a>CLAI-010</td><td>Date of death precedes the date of service</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-011"> </a>CLAI-011</td><td>Inpatient admission spans multiple rate periods. Resubmit separate claims</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-012"> </a>CLAI-012</td><td>Submission not compliant with contractual agreement between provider & payer</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-014"> </a>CLAI-014</td><td>Claim not compliant with Resubmission type (used only for resubmissions)</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-017"> </a>CLAI-017</td><td>Services not available on direct billing</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-018"> </a>CLAI-018</td><td>Claims Recalled By Provider</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CODE-010"> </a>CODE-010</td><td>Activity/diagnosis inconsistent with clinician specialty</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CODE-012"> </a>CODE-012</td><td>Encounter type inconsistent with service(s) / diagnosis</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CODE-013"> </a>CODE-013</td><td>Invalid principal diagnosis</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CODE-014"> </a>CODE-014</td><td>Activity/diagnosis is inconsistent with the patient's age/gender</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CODE-015"> </a>CODE-015</td><td>Activity/diagnosis is inconsistent with the provider type</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-DUPL-001"> </a>DUPL-001</td><td>Claim is a duplicate based on service codes and dates</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-DUPL-002"> </a>DUPL-002</td><td>Payment already made for same/similar service within set time frame</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-MNEC-003"> </a>MNEC-003</td><td>Service is not clinically indicated based on good clinical practice</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-MNEC-004"> </a>MNEC-004</td><td>Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-MNEC-005"> </a>MNEC-005</td><td>Service/supply may be appropriate, but too frequent</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-MNEC-006"> </a>MNEC-006</td><td>Alternative service should have been utilized</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-NCOV-001"> </a>NCOV-001</td><td>Diagnosis(es) is (are) not covered</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-NCOV-002"> </a>NCOV-002</td><td>Pre-existing conditions are not covered</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-NCOV-003"> </a>NCOV-003</td><td>Service(s) is (are) not covered</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-NCOV-025"> </a>NCOV-025</td><td>Service(s) is (are) not performed (used after audit)</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-001"> </a>PRCE-001</td><td>Calculation discrepancy</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-002"> </a>PRCE-002</td><td>Payment is included in the allowance for another service</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-003"> </a>PRCE-003</td><td>Recovery of Payment</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-006"> </a>PRCE-006</td><td>Consultation within free follow up period</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-007"> </a>PRCE-007</td><td>Service has no contract price</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-008"> </a>PRCE-008</td><td>Multiple procedure payment rules incorrectly applied</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-009"> </a>PRCE-009</td><td>Charges inconsistent with clinician specialty</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-010"> </a>PRCE-010</td><td>Use bundled code</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-PRCE-011"> </a>PRCE-011</td><td>Discount discrepancy</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-TIME-001"> </a>TIME-001</td><td>Time limit for submission has expired</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-TIME-002"> </a>TIME-002</td><td>Requested additional information was not received or was not received within time limit</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-TIME-003"> </a>TIME-003</td><td>Appeal procedures not followed or time limits not met</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-COPY-001"> </a>COPY-001</td><td>Deductible/co-pay not collected from member</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-001"> </a>SURC-001</td><td>Severe drug - drug interaction</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-002"> </a>SURC-002</td><td>Severe drug - age contraindication</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-003"> </a>SURC-003</td><td>Severe drug - gender contraindication</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-004"> </a>SURC-004</td><td>Severe drug - diaganosis contraindication</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-005"> </a>SURC-005</td><td>Severe procedure\service - diagnosis contraindication</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-006"> </a>SURC-006</td><td>Severe procedure\service - drug contraindication</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-007"> </a>SURC-007</td><td>Severe procedure\service - procedure contraindication</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-SURC-008"> </a>SURC-008</td><td>Serious safety issue with drug dose</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-WRNG-001"> </a>WRNG-001</td><td>Wrong submission, receiver is not responsible for the payer within this transaction submission.</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-019"> </a>CLAI-019</td><td>Wrong IR-DRG code</td></tr><tr><td style="white-space:nowrap"><a name="http---hcp.org-codes-denial-code-CLAI-020"> </a>CLAI-020</td><td>Missing IR-DRG code</td></tr></table></div>
</text>
<url value="https://fhir-ig-demo/ValueSet/claim-denial-codes"/>
<version value="0.0.1"/>
<name value="Claim Denial Codes"/>
<status value="active"/>
<date value="2021-08-15"/>
<publisher value="HL7 International - HCX"/>
<contact>
<name value="HL7 International - HCX"/>
<telecom>
<system value="url"/>
<value value="https://www.swasth.app/"/>
</telecom>
</contact>
<description
value="This is the value set that includes the codes for understanding of the adjudication result and explaining variance from expected amount"/>
<expansion>
<timestamp value="2021-08-15T08:15:30+05:30"/>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="ELIG-001"/>
<display value="Patient is not a covered member"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="ELIG-005"/>
<display value="Services performed after the last date of coverage"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="ELIG-006"/>
<display
value="Services performed prior to the effective date of coverage"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="ELIG-007"/>
<display value="Services performed by a non-network provider"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-001"/>
<display value="Prior approval is required and was not obtained"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-003"/>
<display value="PriorAuthorizationNumber is invalid"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-004"/>
<display
value="Service(s) is (are) performed outside authorization validity date"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-005"/>
<display
value="Claim information is inconsistent with pre-certified/authorized services"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-006"/>
<display value="Alert drug - drug interaction or drug is contra-indicated"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-007"/>
<display value="Drug duplicate therapy"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-008"/>
<display value="Inappropriate drug dose"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-009"/>
<display value="Prescription out of date"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-010"/>
<display
value="Authorization request overlaps or is within the period of another paid claim or approved authorization"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-011"/>
<display value="Waiting period on pre-existing / specific conditions"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="AUTH-012"/>
<display value="Request for information"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="BENX-002"/>
<display
value="Benefit maximum for this time period or occurrence has been reached"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="BENX-005"/>
<display value="Annual limit/sublimit amount exceeded"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-007"/>
<display
value="Claim is a work-related injury/illness and thus the liability of the employer"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-008"/>
<display
value="Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-009"/>
<display value="Date of birth follows the date of service"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-010"/>
<display value="Date of death precedes the date of service"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-011"/>
<display
value="Inpatient admission spans multiple rate periods. Resubmit separate claims"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-012"/>
<display
value="Submission not compliant with contractual agreement between provider & payer"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-014"/>
<display
value="Claim not compliant with Resubmission type (used only for resubmissions)"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-017"/>
<display value="Services not available on direct billing"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-018"/>
<display value="Claims Recalled By Provider"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CODE-010"/>
<display value="Activity/diagnosis inconsistent with clinician specialty"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CODE-012"/>
<display value="Encounter type inconsistent with service(s) / diagnosis"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CODE-013"/>
<display value="Invalid principal diagnosis"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CODE-014"/>
<display
value="Activity/diagnosis is inconsistent with the patient's age/gender"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CODE-015"/>
<display value="Activity/diagnosis is inconsistent with the provider type"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="DUPL-001"/>
<display value="Claim is a duplicate based on service codes and dates"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="DUPL-002"/>
<display
value="Payment already made for same/similar service within set time frame"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="MNEC-003"/>
<display
value="Service is not clinically indicated based on good clinical practice"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="MNEC-004"/>
<display
value="Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="MNEC-005"/>
<display value="Service/supply may be appropriate, but too frequent"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="MNEC-006"/>
<display value="Alternative service should have been utilized"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="NCOV-001"/>
<display value="Diagnosis(es) is (are) not covered"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="NCOV-002"/>
<display value="Pre-existing conditions are not covered"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="NCOV-003"/>
<display value="Service(s) is (are) not covered"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="NCOV-025"/>
<display value="Service(s) is (are) not performed (used after audit)"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-001"/>
<display value="Calculation discrepancy"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-002"/>
<display value="Payment is included in the allowance for another service"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-003"/>
<display value="Recovery of Payment"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-006"/>
<display value="Consultation within free follow up period"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-007"/>
<display value="Service has no contract price"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-008"/>
<display value="Multiple procedure payment rules incorrectly applied"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-009"/>
<display value="Charges inconsistent with clinician specialty"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-010"/>
<display value="Use bundled code"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="PRCE-011"/>
<display value="Discount discrepancy"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="TIME-001"/>
<display value="Time limit for submission has expired"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="TIME-002"/>
<display
value="Requested additional information was not received or was not received within time limit"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="TIME-003"/>
<display value="Appeal procedures not followed or time limits not met"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="COPY-001"/>
<display value="Deductible/co-pay not collected from member"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-001"/>
<display value="Severe drug - drug interaction"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-002"/>
<display value="Severe drug - age contraindication"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-003"/>
<display value="Severe drug - gender contraindication"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-004"/>
<display value="Severe drug - diaganosis contraindication"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-005"/>
<display value="Severe procedure\service - diagnosis contraindication"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-006"/>
<display value="Severe procedure\service - drug contraindication"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-007"/>
<display value="Severe procedure\service - procedure contraindication"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="SURC-008"/>
<display value="Serious safety issue with drug dose"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="WRNG-001"/>
<display
value="Wrong submission, receiver is not responsible for the payer within this transaction submission."/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-019"/>
<display value="Wrong IR-DRG code"/>
</contains>
<contains>
<system value="http://hcp.org/codes/denial-code"/>
<code value="CLAI-020"/>
<display value="Missing IR-DRG code"/>
</contains>
</expansion>
</ValueSet>