FHIR Implementation Guide for HCX
0.7.0 - CI Build
FHIR Implementation Guide for HCX
0.7.0 - CI Build
FHIR Implementation Guide for HCX - Local Development build (v0.7.0). See the Directory of published versions
{
"resourceType" : "ValueSet",
"id" : "claim-denial-codes",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This value set contains 65 concepts</p><p>All codes in this table are from the 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>"
},
"url" : "https://swasth-digital-health-foundation.github.io/standards/v0.7/ValueSet-claim-denial-codes.html",
"version" : "0.7.0",
"name" : "ClaimDenialCodes",
"status" : "active",
"date" : "2021-08-15",
"publisher" : "HCX Open Community",
"contact" : [
{
"name" : "HCX Open Community",
"telecom" : [
{
"system" : "url",
"value" : "http://hcxprotocol.io/"
}
]
}
],
"description" : "This is the value set that includes the codes for understanding of the adjudication result and explaining variance from expected amount",
"expansion" : {
"timestamp" : "2021-08-15T08:15:30+05:30",
"contains" : [
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "ELIG-001",
"display" : "Patient is not a covered member"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "ELIG-005",
"display" : "Services performed after the last date of coverage"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "ELIG-006",
"display" : "Services performed prior to the effective date of coverage"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "ELIG-007",
"display" : "Services performed by a non-network provider"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-001",
"display" : "Prior approval is required and was not obtained"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-003",
"display" : "PriorAuthorizationNumber is invalid"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-004",
"display" : "Service(s) is (are) performed outside authorization validity date"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-005",
"display" : "Claim information is inconsistent with pre-certified/authorized services"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-006",
"display" : "Alert drug - drug interaction or drug is contra-indicated"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-007",
"display" : "Drug duplicate therapy"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-008",
"display" : "Inappropriate drug dose"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-009",
"display" : "Prescription out of date"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-010",
"display" : "Authorization request overlaps or is within the period of another paid claim or approved authorization"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-011",
"display" : "Waiting period on pre-existing / specific conditions"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "AUTH-012",
"display" : "Request for information"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "BENX-002",
"display" : "Benefit maximum for this time period or occurrence has been reached"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "BENX-005",
"display" : "Annual limit/sublimit amount exceeded"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-007",
"display" : "Claim is a work-related injury/illness and thus the liability of the employer"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-008",
"display" : "Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-009",
"display" : "Date of birth follows the date of service"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-010",
"display" : "Date of death precedes the date of service"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-011",
"display" : "Inpatient admission spans multiple rate periods. Resubmit separate claims"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-012",
"display" : "Submission not compliant with contractual agreement between provider & payer"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-014",
"display" : "Claim not compliant with Resubmission type (used only for resubmissions)"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-017",
"display" : "Services not available on direct billing"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-018",
"display" : "Claims Recalled By Provider"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CODE-010",
"display" : "Activity/diagnosis inconsistent with clinician specialty"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CODE-012",
"display" : "Encounter type inconsistent with service(s) / diagnosis"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CODE-013",
"display" : "Invalid principal diagnosis"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CODE-014",
"display" : "Activity/diagnosis is inconsistent with the patient's age/gender"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CODE-015",
"display" : "Activity/diagnosis is inconsistent with the provider type"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "DUPL-001",
"display" : "Claim is a duplicate based on service codes and dates"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "DUPL-002",
"display" : "Payment already made for same/similar service within set time frame"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "MNEC-003",
"display" : "Service is not clinically indicated based on good clinical practice"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "MNEC-004",
"display" : "Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "MNEC-005",
"display" : "Service/supply may be appropriate, but too frequent"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "MNEC-006",
"display" : "Alternative service should have been utilized"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "NCOV-001",
"display" : "Diagnosis(es) is (are) not covered"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "NCOV-002",
"display" : "Pre-existing conditions are not covered"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "NCOV-003",
"display" : "Service(s) is (are) not covered"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "NCOV-025",
"display" : "Service(s) is (are) not performed (used after audit)"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-001",
"display" : "Calculation discrepancy"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-002",
"display" : "Payment is included in the allowance for another service"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-003",
"display" : "Recovery of Payment"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-006",
"display" : "Consultation within free follow up period"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-007",
"display" : "Service has no contract price"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-008",
"display" : "Multiple procedure payment rules incorrectly applied"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-009",
"display" : "Charges inconsistent with clinician specialty"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-010",
"display" : "Use bundled code"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "PRCE-011",
"display" : "Discount discrepancy"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "TIME-001",
"display" : "Time limit for submission has expired"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "TIME-002",
"display" : "Requested additional information was not received or was not received within time limit"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "TIME-003",
"display" : "Appeal procedures not followed or time limits not met"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "COPY-001",
"display" : "Deductible/co-pay not collected from member"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-001",
"display" : "Severe drug - drug interaction"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-002",
"display" : "Severe drug - age contraindication"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-003",
"display" : "Severe drug - gender contraindication"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-004",
"display" : "Severe drug - diaganosis contraindication"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-005",
"display" : "Severe procedure\\service - diagnosis contraindication"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-006",
"display" : "Severe procedure\\service - drug contraindication"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-007",
"display" : "Severe procedure\\service - procedure contraindication"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "SURC-008",
"display" : "Serious safety issue with drug dose"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "WRNG-001",
"display" : "Wrong submission, receiver is not responsible for the payer within this transaction submission."
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-019",
"display" : "Wrong IR-DRG code"
},
{
"system" : "http://hcp.org/codes/denial-code",
"code" : "CLAI-020",
"display" : "Missing IR-DRG code"
}
]
}
}