FHIR Implementation Guide for HCX
0.9.0 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.9.0). See the Directory of published versions

ValueSet: HCX Claim Error Codes

Summary

Defining URL:https://ig.hcxprotocol.io/v0.9/ValueSet-claim-error-codes.html
Version:0.9.0
Name:ClaimErrorCodes
Status:Active as of 2022-08-01
Definition:

This is the value set for claim error codes

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 66 concepts

CodeSystemDisplay
  ELIG-001http://hcxprotocol.io/codes/claim-error-codesPatient is not a covered member
  ELIG-005http://hcxprotocol.io/codes/claim-error-codesServices performed after the last date of coverage
  ELIG-006http://hcxprotocol.io/codes/claim-error-codesServices performed prior to the effective date of coverage
  ELIG-007http://hcxprotocol.io/codes/claim-error-codesServices performed by a non-network provider
  AUTH-001http://hcxprotocol.io/codes/claim-error-codesPrior approval is required and was not obtained
  AUTH-003http://hcxprotocol.io/codes/claim-error-codesPriorAuthorizationNumber is invalid
  AUTH-004http://hcxprotocol.io/codes/claim-error-codesService(s) is (are) performed outside authorization validity date
  AUTH-005http://hcxprotocol.io/codes/claim-error-codesClaim information is inconsistent with pre-certified/authorized services
  AUTH-006http://hcxprotocol.io/codes/claim-error-codesAlert drug - drug interaction or drug is contra-indicated
  AUTH-007http://hcxprotocol.io/codes/claim-error-codesDrug duplicate therapy
  AUTH-008http://hcxprotocol.io/codes/claim-error-codesInappropriate drug dose
  AUTH-009http://hcxprotocol.io/codes/claim-error-codesPrescription out of date
  AUTH-010http://hcxprotocol.io/codes/claim-error-codesAuthorization request overlaps or is within the period of another paid claim or approved authorization
  AUTH-011http://hcxprotocol.io/codes/claim-error-codesWaiting period on pre-existing / specific conditions
  AUTH-012http://hcxprotocol.io/codes/claim-error-codesRequest for information
  AUTH-013http://hcxprotocol.io/codes/claim-error-codesPatient consent is not provided or invalid
  BENX-002http://hcxprotocol.io/codes/claim-error-codesBenefit maximum for this time period or occurrence has been reached
  BENX-005http://hcxprotocol.io/codes/claim-error-codesAnnual limit/sublimit amount exceeded
  CLAI-007http://hcxprotocol.io/codes/claim-error-codesClaim is a work-related injury/illness and thus the liability of the employer
  CLAI-008http://hcxprotocol.io/codes/claim-error-codesClaim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay
  CLAI-009http://hcxprotocol.io/codes/claim-error-codesDate of birth follows the date of service
  CLAI-010http://hcxprotocol.io/codes/claim-error-codesDate of death precedes the date of service
  CLAI-011http://hcxprotocol.io/codes/claim-error-codesInpatient admission spans multiple rate periods. Resubmit separate claims
  CLAI-012http://hcxprotocol.io/codes/claim-error-codesSubmission not compliant with contractual agreement between provider & payer
  CLAI-014http://hcxprotocol.io/codes/claim-error-codesClaim not compliant with Resubmission type (used only for resubmissions)
  CLAI-017http://hcxprotocol.io/codes/claim-error-codesServices not available on direct billing
  CLAI-018http://hcxprotocol.io/codes/claim-error-codesClaims Recalled By Provider
  CODE-010http://hcxprotocol.io/codes/claim-error-codesActivity/diagnosis inconsistent with clinician specialty
  CODE-012http://hcxprotocol.io/codes/claim-error-codesEncounter type inconsistent with service(s) / diagnosis
  CODE-013http://hcxprotocol.io/codes/claim-error-codesInvalid principal diagnosis
  CODE-014http://hcxprotocol.io/codes/claim-error-codesActivity/diagnosis is inconsistent with the patient's age/gender
  CODE-015http://hcxprotocol.io/codes/claim-error-codesActivity/diagnosis is inconsistent with the provider type
  DUPL-001http://hcxprotocol.io/codes/claim-error-codesClaim is a duplicate based on service codes and dates
  DUPL-002http://hcxprotocol.io/codes/claim-error-codesPayment already made for same/similar service within set time frame
  MNEC-003http://hcxprotocol.io/codes/claim-error-codesService is not clinically indicated based on good clinical practice
  MNEC-004http://hcxprotocol.io/codes/claim-error-codesService is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities
  MNEC-005http://hcxprotocol.io/codes/claim-error-codesService/supply may be appropriate, but too frequent
  MNEC-006http://hcxprotocol.io/codes/claim-error-codesAlternative service should have been utilized
  NCOV-001http://hcxprotocol.io/codes/claim-error-codesDiagnosis(es) is (are) not covered
  NCOV-002http://hcxprotocol.io/codes/claim-error-codesPre-existing conditions are not covered
  NCOV-003http://hcxprotocol.io/codes/claim-error-codesService(s) is (are) not covered
  NCOV-025http://hcxprotocol.io/codes/claim-error-codesService(s) is (are) not performed (used after audit)
  PRCE-001http://hcxprotocol.io/codes/claim-error-codesCalculation discrepancy
  PRCE-002http://hcxprotocol.io/codes/claim-error-codesPayment is included in the allowance for another service
  PRCE-003http://hcxprotocol.io/codes/claim-error-codesRecovery of Payment
  PRCE-006http://hcxprotocol.io/codes/claim-error-codesConsultation within free follow up period
  PRCE-007http://hcxprotocol.io/codes/claim-error-codesService has no contract price
  PRCE-008http://hcxprotocol.io/codes/claim-error-codesMultiple procedure payment rules incorrectly applied
  PRCE-009http://hcxprotocol.io/codes/claim-error-codesCharges inconsistent with clinician specialty
  PRCE-010http://hcxprotocol.io/codes/claim-error-codesUse bundled code
  PRCE-011http://hcxprotocol.io/codes/claim-error-codesDiscount discrepancy
  TIME-001http://hcxprotocol.io/codes/claim-error-codesTime limit for submission has expired
  TIME-002http://hcxprotocol.io/codes/claim-error-codesRequested additional information was not received or was not received within time limit
  TIME-003http://hcxprotocol.io/codes/claim-error-codesAppeal procedures not followed or time limits not met
  COPY-001http://hcxprotocol.io/codes/claim-error-codesDeductible/co-pay not collected from member
  SURC-001http://hcxprotocol.io/codes/claim-error-codesSevere drug - drug interaction
  SURC-002http://hcxprotocol.io/codes/claim-error-codesSevere drug - age contraindication
  SURC-003http://hcxprotocol.io/codes/claim-error-codesSevere drug - gender contraindication
  SURC-004http://hcxprotocol.io/codes/claim-error-codesSevere drug - diaganosis contraindication
  SURC-005http://hcxprotocol.io/codes/claim-error-codesSevere procedure\service - diagnosis contraindication
  SURC-006http://hcxprotocol.io/codes/claim-error-codesSevere procedure\service - drug contraindication
  SURC-007http://hcxprotocol.io/codes/claim-error-codesSevere procedure\service - procedure contraindication
  SURC-008http://hcxprotocol.io/codes/claim-error-codesSerious safety issue with drug dose
  WRNG-001http://hcxprotocol.io/codes/claim-error-codesWrong submission, receiver is not responsible for the payer within this transaction submission.
  CLAI-019http://hcxprotocol.io/codes/claim-error-codesWrong IR-DRG code
  CLAI-020http://hcxprotocol.io/codes/claim-error-codesMissing 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