FHIR Implementation Guide for HCX
0.8.0 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.8.0). See the Directory of published versions

ValueSet: HCX Claim Denial Codes

Summary

Defining URL:https://ig.hcxprotocol.io/v0.8/ValueSet-claim-denial-codes.html
Version:0.8.0
Name:ClaimDenialCodes
Status:Active as of 2021-08-15
Definition:

This is the value set that includes the codes for understanding of the adjudication result and explaining variance from expected amount

Publisher:HCX Open Community
Source Resource:XML / JSON / Turtle

References

Logical Definition (CLD)

No formal definition provided for this ValueSet

 

Expansion

This value set contains 65 concepts

CodeSystemDisplay
  ELIG-001http://hcxprotocol.io/codes/denial-codePatient is not a covered member
  ELIG-005http://hcxprotocol.io/codes/denial-codeServices performed after the last date of coverage
  ELIG-006http://hcxprotocol.io/codes/denial-codeServices performed prior to the effective date of coverage
  ELIG-007http://hcxprotocol.io/codes/denial-codeServices performed by a non-network provider
  AUTH-001http://hcxprotocol.io/codes/denial-codePrior approval is required and was not obtained
  AUTH-003http://hcxprotocol.io/codes/denial-codePriorAuthorizationNumber is invalid
  AUTH-004http://hcxprotocol.io/codes/denial-codeService(s) is (are) performed outside authorization validity date
  AUTH-005http://hcxprotocol.io/codes/denial-codeClaim information is inconsistent with pre-certified/authorized services
  AUTH-006http://hcxprotocol.io/codes/denial-codeAlert drug - drug interaction or drug is contra-indicated
  AUTH-007http://hcxprotocol.io/codes/denial-codeDrug duplicate therapy
  AUTH-008http://hcxprotocol.io/codes/denial-codeInappropriate drug dose
  AUTH-009http://hcxprotocol.io/codes/denial-codePrescription out of date
  AUTH-010http://hcxprotocol.io/codes/denial-codeAuthorization request overlaps or is within the period of another paid claim or approved authorization
  AUTH-011http://hcxprotocol.io/codes/denial-codeWaiting period on pre-existing / specific conditions
  AUTH-012http://hcxprotocol.io/codes/denial-codeRequest for information
  BENX-002http://hcxprotocol.io/codes/denial-codeBenefit maximum for this time period or occurrence has been reached
  BENX-005http://hcxprotocol.io/codes/denial-codeAnnual limit/sublimit amount exceeded
  CLAI-007http://hcxprotocol.io/codes/denial-codeClaim is a work-related injury/illness and thus the liability of the employer
  CLAI-008http://hcxprotocol.io/codes/denial-codeClaim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay
  CLAI-009http://hcxprotocol.io/codes/denial-codeDate of birth follows the date of service
  CLAI-010http://hcxprotocol.io/codes/denial-codeDate of death precedes the date of service
  CLAI-011http://hcxprotocol.io/codes/denial-codeInpatient admission spans multiple rate periods. Resubmit separate claims
  CLAI-012http://hcxprotocol.io/codes/denial-codeSubmission not compliant with contractual agreement between provider & payer
  CLAI-014http://hcxprotocol.io/codes/denial-codeClaim not compliant with Resubmission type (used only for resubmissions)
  CLAI-017http://hcxprotocol.io/codes/denial-codeServices not available on direct billing
  CLAI-018http://hcxprotocol.io/codes/denial-codeClaims Recalled By Provider
  CODE-010http://hcxprotocol.io/codes/denial-codeActivity/diagnosis inconsistent with clinician specialty
  CODE-012http://hcxprotocol.io/codes/denial-codeEncounter type inconsistent with service(s) / diagnosis
  CODE-013http://hcxprotocol.io/codes/denial-codeInvalid principal diagnosis
  CODE-014http://hcxprotocol.io/codes/denial-codeActivity/diagnosis is inconsistent with the patient's age/gender
  CODE-015http://hcxprotocol.io/codes/denial-codeActivity/diagnosis is inconsistent with the provider type
  DUPL-001http://hcxprotocol.io/codes/denial-codeClaim is a duplicate based on service codes and dates
  DUPL-002http://hcxprotocol.io/codes/denial-codePayment already made for same/similar service within set time frame
  MNEC-003http://hcxprotocol.io/codes/denial-codeService is not clinically indicated based on good clinical practice
  MNEC-004http://hcxprotocol.io/codes/denial-codeService is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities
  MNEC-005http://hcxprotocol.io/codes/denial-codeService/supply may be appropriate, but too frequent
  MNEC-006http://hcxprotocol.io/codes/denial-codeAlternative service should have been utilized
  NCOV-001http://hcxprotocol.io/codes/denial-codeDiagnosis(es) is (are) not covered
  NCOV-002http://hcxprotocol.io/codes/denial-codePre-existing conditions are not covered
  NCOV-003http://hcxprotocol.io/codes/denial-codeService(s) is (are) not covered
  NCOV-025http://hcxprotocol.io/codes/denial-codeService(s) is (are) not performed (used after audit)
  PRCE-001http://hcxprotocol.io/codes/denial-codeCalculation discrepancy
  PRCE-002http://hcxprotocol.io/codes/denial-codePayment is included in the allowance for another service
  PRCE-003http://hcxprotocol.io/codes/denial-codeRecovery of Payment
  PRCE-006http://hcxprotocol.io/codes/denial-codeConsultation within free follow up period
  PRCE-007http://hcxprotocol.io/codes/denial-codeService has no contract price
  PRCE-008http://hcxprotocol.io/codes/denial-codeMultiple procedure payment rules incorrectly applied
  PRCE-009http://hcxprotocol.io/codes/denial-codeCharges inconsistent with clinician specialty
  PRCE-010http://hcxprotocol.io/codes/denial-codeUse bundled code
  PRCE-011http://hcxprotocol.io/codes/denial-codeDiscount discrepancy
  TIME-001http://hcxprotocol.io/codes/denial-codeTime limit for submission has expired
  TIME-002http://hcxprotocol.io/codes/denial-codeRequested additional information was not received or was not received within time limit
  TIME-003http://hcxprotocol.io/codes/denial-codeAppeal procedures not followed or time limits not met
  COPY-001http://hcxprotocol.io/codes/denial-codeDeductible/co-pay not collected from member
  SURC-001http://hcxprotocol.io/codes/denial-codeSevere drug - drug interaction
  SURC-002http://hcxprotocol.io/codes/denial-codeSevere drug - age contraindication
  SURC-003http://hcxprotocol.io/codes/denial-codeSevere drug - gender contraindication
  SURC-004http://hcxprotocol.io/codes/denial-codeSevere drug - diaganosis contraindication
  SURC-005http://hcxprotocol.io/codes/denial-codeSevere procedure\service - diagnosis contraindication
  SURC-006http://hcxprotocol.io/codes/denial-codeSevere procedure\service - drug contraindication
  SURC-007http://hcxprotocol.io/codes/denial-codeSevere procedure\service - procedure contraindication
  SURC-008http://hcxprotocol.io/codes/denial-codeSerious safety issue with drug dose
  WRNG-001http://hcxprotocol.io/codes/denial-codeWrong submission, receiver is not responsible for the payer within this transaction submission.
  CLAI-019http://hcxprotocol.io/codes/denial-codeWrong IR-DRG code
  CLAI-020http://hcxprotocol.io/codes/denial-codeMissing IR-DRG code

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
Source The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code