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
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ValueSet;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "claim-denial-codes"];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.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>"
];
fhir:ValueSet.url [ fhir:value "https://swasth-digital-health-foundation.github.io/standards/v0.7/ValueSet-claim-denial-codes.html"];
fhir:ValueSet.version [ fhir:value "0.7.0"];
fhir:ValueSet.name [ fhir:value "ClaimDenialCodes"];
fhir:ValueSet.status [ fhir:value "active"];
fhir:ValueSet.date [ fhir:value "2021-08-15"^^xsd:date];
fhir:ValueSet.publisher [ fhir:value "HCX Open Community"];
fhir:ValueSet.contact [
fhir:index 0;
fhir:ContactDetail.name [ fhir:value "HCX Open Community" ];
fhir:ContactDetail.telecom [
fhir:index 0;
fhir:ContactPoint.system [ fhir:value "url" ];
fhir:ContactPoint.value [ fhir:value "http://hcxprotocol.io/" ] ]
];
fhir:ValueSet.description [ fhir:value "This is the value set that includes the codes for understanding of the adjudication result and explaining variance from expected amount"];
fhir:ValueSet.expansion [
fhir:ValueSet.expansion.timestamp [ fhir:value "2021-08-15T08:15:30+05:30"^^xsd:dateTime ];
fhir:ValueSet.expansion.contains [
fhir:index 0;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "ELIG-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Patient is not a covered member" ] ], [
fhir:index 1;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "ELIG-005" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Services performed after the last date of coverage" ] ], [
fhir:index 2;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "ELIG-006" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Services performed prior to the effective date of coverage" ] ], [
fhir:index 3;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "ELIG-007" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Services performed by a non-network provider" ] ], [
fhir:index 4;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Prior approval is required and was not obtained" ] ], [
fhir:index 5;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-003" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "PriorAuthorizationNumber is invalid" ] ], [
fhir:index 6;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-004" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service(s) is (are) performed outside authorization validity date" ] ], [
fhir:index 7;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-005" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Claim information is inconsistent with pre-certified/authorized services" ] ], [
fhir:index 8;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-006" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Alert drug - drug interaction or drug is contra-indicated" ] ], [
fhir:index 9;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-007" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Drug duplicate therapy" ] ], [
fhir:index 10;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-008" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Inappropriate drug dose" ] ], [
fhir:index 11;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-009" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Prescription out of date" ] ], [
fhir:index 12;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-010" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Authorization request overlaps or is within the period of another paid claim or approved authorization" ] ], [
fhir:index 13;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-011" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Waiting period on pre-existing / specific conditions" ] ], [
fhir:index 14;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "AUTH-012" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Request for information" ] ], [
fhir:index 15;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "BENX-002" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Benefit maximum for this time period or occurrence has been reached" ] ], [
fhir:index 16;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "BENX-005" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Annual limit/sublimit amount exceeded" ] ], [
fhir:index 17;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-007" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Claim is a work-related injury/illness and thus the liability of the employer" ] ], [
fhir:index 18;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-008" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay" ] ], [
fhir:index 19;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-009" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Date of birth follows the date of service" ] ], [
fhir:index 20;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-010" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Date of death precedes the date of service" ] ], [
fhir:index 21;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-011" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Inpatient admission spans multiple rate periods. Resubmit separate claims" ] ], [
fhir:index 22;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-012" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Submission not compliant with contractual agreement between provider & payer" ] ], [
fhir:index 23;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-014" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Claim not compliant with Resubmission type (used only for resubmissions)" ] ], [
fhir:index 24;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-017" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Services not available on direct billing" ] ], [
fhir:index 25;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-018" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Claims Recalled By Provider" ] ], [
fhir:index 26;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CODE-010" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Activity/diagnosis inconsistent with clinician specialty" ] ], [
fhir:index 27;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CODE-012" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Encounter type inconsistent with service(s) / diagnosis" ] ], [
fhir:index 28;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CODE-013" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Invalid principal diagnosis" ] ], [
fhir:index 29;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CODE-014" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Activity/diagnosis is inconsistent with the patient's age/gender" ] ], [
fhir:index 30;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CODE-015" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Activity/diagnosis is inconsistent with the provider type" ] ], [
fhir:index 31;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "DUPL-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Claim is a duplicate based on service codes and dates" ] ], [
fhir:index 32;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "DUPL-002" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Payment already made for same/similar service within set time frame" ] ], [
fhir:index 33;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "MNEC-003" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service is not clinically indicated based on good clinical practice" ] ], [
fhir:index 34;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "MNEC-004" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities" ] ], [
fhir:index 35;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "MNEC-005" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service/supply may be appropriate, but too frequent" ] ], [
fhir:index 36;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "MNEC-006" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Alternative service should have been utilized" ] ], [
fhir:index 37;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "NCOV-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Diagnosis(es) is (are) not covered" ] ], [
fhir:index 38;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "NCOV-002" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Pre-existing conditions are not covered" ] ], [
fhir:index 39;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "NCOV-003" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service(s) is (are) not covered" ] ], [
fhir:index 40;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "NCOV-025" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service(s) is (are) not performed (used after audit)" ] ], [
fhir:index 41;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Calculation discrepancy" ] ], [
fhir:index 42;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-002" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Payment is included in the allowance for another service" ] ], [
fhir:index 43;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-003" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Recovery of Payment" ] ], [
fhir:index 44;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-006" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Consultation within free follow up period" ] ], [
fhir:index 45;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-007" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Service has no contract price" ] ], [
fhir:index 46;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-008" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Multiple procedure payment rules incorrectly applied" ] ], [
fhir:index 47;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-009" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Charges inconsistent with clinician specialty" ] ], [
fhir:index 48;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-010" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Use bundled code" ] ], [
fhir:index 49;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "PRCE-011" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Discount discrepancy" ] ], [
fhir:index 50;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "TIME-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Time limit for submission has expired" ] ], [
fhir:index 51;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "TIME-002" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Requested additional information was not received or was not received within time limit" ] ], [
fhir:index 52;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "TIME-003" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Appeal procedures not followed or time limits not met" ] ], [
fhir:index 53;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "COPY-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Deductible/co-pay not collected from member" ] ], [
fhir:index 54;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe drug - drug interaction" ] ], [
fhir:index 55;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-002" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe drug - age contraindication" ] ], [
fhir:index 56;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-003" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe drug - gender contraindication" ] ], [
fhir:index 57;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-004" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe drug - diaganosis contraindication" ] ], [
fhir:index 58;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-005" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe procedure\\service - diagnosis contraindication" ] ], [
fhir:index 59;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-006" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe procedure\\service - drug contraindication" ] ], [
fhir:index 60;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-007" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Severe procedure\\service - procedure contraindication" ] ], [
fhir:index 61;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "SURC-008" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Serious safety issue with drug dose" ] ], [
fhir:index 62;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "WRNG-001" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Wrong submission, receiver is not responsible for the payer within this transaction submission." ] ], [
fhir:index 63;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-019" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Wrong IR-DRG code" ] ], [
fhir:index 64;
fhir:ValueSet.expansion.contains.system [ fhir:value "http://hcp.org/codes/denial-code" ];
fhir:ValueSet.expansion.contains.code [ fhir:value "CLAI-020" ];
fhir:ValueSet.expansion.contains.display [ fhir:value "Missing IR-DRG code" ] ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.