: Billing Rule Class - JSON Representation
Raw json | Download
{
"resourceType" : "CodeSystem",
"id" : "billing-rule-class",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem billing-rule-class</b></p><a name=\"billing-rule-class\"> </a><a name=\"hcbilling-rule-class\"> </a><p><b>Properties</b></p><p><b>This code system defines the following properties for its concepts</b></p><table class=\"grid\"><tr><td><b>Name</b></td><td><b>Code</b></td><td><b>URI</b></td><td><b>Type</b></td><td><b>Description</b></td></tr><tr><td>defaultEffect</td><td>defaultEffect</td><td>https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#defaultEffect</td><td>Coding</td><td>Default effect when a rule instance does not declare a more specific supported effect</td></tr><tr><td>requiredFactTypes</td><td>requiredFactTypes</td><td>https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#requiredFactTypes</td><td>Coding</td><td>Declared floor of fact categories for this class. A conforming evaluator derives the authoritative required-fact set from the rule class together with its instance parameters; that derived set is never smaller than this floor and may be larger.</td></tr><tr><td>since</td><td>since</td><td>https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#since</td><td>string</td><td>Semantic major in which this immutable class concept was introduced</td></tr><tr><td>replacedBy</td><td>replacedBy</td><td>https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#replacedBy</td><td>Coding</td><td>Successor class concept when this concept is retired</td></tr></table><p><b>Concepts</b></p><p>This case-sensitive code system <code>https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td><td><b>defaultEffect</b></td><td><b>requiredFactTypes</b></td><td><b>since</b></td></tr><tr><td style=\"white-space:nowrap\">quantity-limit<a name=\"billing-rule-class-quantity-limit\"> </a></td><td>Quantity limit</td><td>Limits the number of matching services within a counting scope.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-occurrence}\">Service occurrence</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">value-limit<a name=\"billing-rule-class-value-limit\"> </a></td><td>Value limit</td><td>Limits the sum of a measure, such as currency, points, or minutes, within a counting scope.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-value}\">Service value</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">mutual-exclusion<a name=\"billing-rule-class-mutual-exclusion\"> </a></td><td>Mutual exclusion</td><td>Forbids selected services from occurring together within a counting scope.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-occurrence}\">Service occurrence</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">inclusive-component<a name=\"billing-rule-class-inclusive-component\"> </a></td><td>Inclusive component</td><td>Declares that a component service is included in a containing service and is not separately billable in the stated direction.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-occurrence}\">Service occurrence</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">companion-required<a name=\"billing-rule-class-companion-required\"> </a></td><td>Companion required</td><td>Requires one or more companion services, optionally with ordering constraints, within a counting scope.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-occurrence}\">Service occurrence</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">repeat-interval<a name=\"billing-rule-class-repeat-interval\"> </a></td><td>Repeat interval</td><td>Requires a minimum interval before a matching service may be repeated for the same counting subject.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-occurrence}\">Service occurrence</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">diagnosis-requirement<a name=\"billing-rule-class-diagnosis-requirement\"> </a></td><td>Diagnosis requirement</td><td>Requires or forbids a diagnosis matching a declared selector, certainty, and time window.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact diagnosis}\">Diagnosis</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">procedure-finding-requirement<a name=\"billing-rule-class-procedure-finding-requirement\"> </a></td><td>Procedure or finding requirement</td><td>Requires a documented procedure, finding, or measurement matching the declared selector.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact procedure}\">Procedure</a>, <a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact finding}\">Finding</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">patient-attribute-constraint<a name=\"billing-rule-class-patient-attribute-constraint\"> </a></td><td>Patient attribute constraint</td><td>Constrains applicability using declared patient demographic or status predicates.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact patient-attribute}\">Patient attribute</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">provider-eligibility<a name=\"billing-rule-class-provider-eligibility\"> </a></td><td>Provider eligibility</td><td>Constrains applicability using declared provider specialty, authorization, or relationship predicates.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact provider-eligibility}\">Provider eligibility</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">setting-constraint<a name=\"billing-rule-class-setting-constraint\"> </a></td><td>Setting constraint</td><td>Constrains applicability using declared care setting, billing case, place, time, or treatment-kind predicates.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact care-setting}\">Care setting</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">contract-participation<a name=\"billing-rule-class-contract-participation\"> </a></td><td>Contract participation</td><td>Requires participation in a declared contract or module by the patient, provider, or practice.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect reject}\">Reject</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact contract-participation}\">Contract participation</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">accompanying-information-required<a name=\"billing-rule-class-accompanying-information-required\"> </a></td><td>Accompanying information required</td><td>Requires declared structured information, justification, report, or itemized cost evidence.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect requires-justification}\">Requires justification</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact accompanying-information}\">Accompanying information</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">prior-authorization-required<a name=\"billing-rule-class-prior-authorization-required\"> </a></td><td>Prior authorization required</td><td>Requires an approved plan or authorization before the service is rendered or billed.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect requires-approval}\">Requires approval</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact prior-authorization}\">Prior authorization</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">patient-agreement-required<a name=\"billing-rule-class-patient-agreement-required\"> </a></td><td>Patient agreement required</td><td>Requires a declared patient agreement before billing under the stated conditions.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect requires-agreement}\">Requires agreement</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact patient-agreement}\">Patient agreement</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">factor-bound<a name=\"billing-rule-class-factor-bound\"> </a></td><td>Factor bound</td><td>Applies declared multiplier bounds and maps threshold crossings to a declared effect.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect requires-justification}\">Requires justification</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact billing-factor}\">Billing factor</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">analogue-service<a name=\"billing-rule-class-analogue-service\"> </a></td><td>Analogue service</td><td>Constrains billing of an unlisted service by reference to a declared equivalent listed service.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect requires-justification}\">Requires justification</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact analogue-reference}\">Analogue reference</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">cost-reimbursement-constraint<a name=\"billing-rule-class-cost-reimbursement-constraint\"> </a></td><td>Cost reimbursement constraint</td><td>Constrains material or laboratory cost reimbursement using declared evidence requirements or limits.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect requires-justification}\">Requires justification</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact cost-evidence}\">Cost evidence</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">quota-degression<a name=\"billing-rule-class-quota-degression\"> </a></td><td>Quota degression</td><td>Applies a declared reduced valuation after a volume threshold is exceeded.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect price-adjust}\">Price adjustment</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact volume}\">Volume</a>, <a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact service-value}\">Service value</a></td><td>1</td></tr><tr><td style=\"white-space:nowrap\">plan-finding-entitlement<a name=\"billing-rule-class-plan-finding-entitlement\"> </a></td><td>Plan and finding entitlement</td><td>Derives a permitted treatment path or subsidy from declared findings and an approved plan.</td><td><a href=\"CodeSystem-billing-rule-effect.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect price-adjust}\">Price adjustment</a></td><td><a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact approved-plan}\">Approved plan</a>, <a href=\"CodeSystem-billing-required-fact.html\" title=\"{https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact finding}\">Finding</a></td><td>1</td></tr></table></div>"
},
"url" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class",
"identifier" : [
{
"system" : "urn:ietf:rfc:3986",
"value" : "urn:oid:2.16.840.1.113883.3.7985.16.20"
}
],
"version" : "1",
"name" : "BillingRuleClassCS",
"title" : "Billing Rule Class",
"status" : "active",
"experimental" : false,
"date" : "2026-08-22T18:18:46+02:00",
"publisher" : "cognovis GmbH",
"contact" : [
{
"name" : "cognovis GmbH",
"telecom" : [
{
"system" : "url",
"value" : "https://www.cognovis.de"
},
{
"system" : "email",
"value" : "info@cognovis.de"
}
]
}
],
"description" : "Regime-neutral classes of declarative billing rules. A rule class names an observable evaluation algorithm; fee schedules and contracts provide instance parameters.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "DE"
}
]
}
],
"copyright" : "Copyright 2026+ cognovis GmbH. Cognovis-authored material is licensed under Apache-2.0; third-party material retains its own terms as documented in THIRD_PARTY_NOTICES.md.",
"caseSensitive" : true,
"content" : "complete",
"count" : 20,
"property" : [
{
"code" : "defaultEffect",
"uri" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#defaultEffect",
"description" : "Default effect when a rule instance does not declare a more specific supported effect",
"type" : "Coding"
},
{
"code" : "requiredFactTypes",
"uri" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#requiredFactTypes",
"description" : "Declared floor of fact categories for this class. A conforming evaluator derives the authoritative required-fact set from the rule class together with its instance parameters; that derived set is never smaller than this floor and may be larger.",
"type" : "Coding"
},
{
"code" : "since",
"uri" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#since",
"description" : "Semantic major in which this immutable class concept was introduced",
"type" : "string"
},
{
"code" : "replacedBy",
"uri" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#replacedBy",
"description" : "Successor class concept when this concept is retired",
"type" : "Coding"
}
],
"concept" : [
{
"code" : "quantity-limit",
"display" : "Quantity limit",
"definition" : "Limits the number of matching services within a counting scope.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-occurrence"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "value-limit",
"display" : "Value limit",
"definition" : "Limits the sum of a measure, such as currency, points, or minutes, within a counting scope.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-value"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "mutual-exclusion",
"display" : "Mutual exclusion",
"definition" : "Forbids selected services from occurring together within a counting scope.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-occurrence"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "inclusive-component",
"display" : "Inclusive component",
"definition" : "Declares that a component service is included in a containing service and is not separately billable in the stated direction.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-occurrence"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "companion-required",
"display" : "Companion required",
"definition" : "Requires one or more companion services, optionally with ordering constraints, within a counting scope.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-occurrence"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "repeat-interval",
"display" : "Repeat interval",
"definition" : "Requires a minimum interval before a matching service may be repeated for the same counting subject.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-occurrence"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "diagnosis-requirement",
"display" : "Diagnosis requirement",
"definition" : "Requires or forbids a diagnosis matching a declared selector, certainty, and time window.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "diagnosis"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "procedure-finding-requirement",
"display" : "Procedure or finding requirement",
"definition" : "Requires a documented procedure, finding, or measurement matching the declared selector.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "procedure"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "finding"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "patient-attribute-constraint",
"display" : "Patient attribute constraint",
"definition" : "Constrains applicability using declared patient demographic or status predicates.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "patient-attribute"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "provider-eligibility",
"display" : "Provider eligibility",
"definition" : "Constrains applicability using declared provider specialty, authorization, or relationship predicates.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "provider-eligibility"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "setting-constraint",
"display" : "Setting constraint",
"definition" : "Constrains applicability using declared care setting, billing case, place, time, or treatment-kind predicates.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "care-setting"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "contract-participation",
"display" : "Contract participation",
"definition" : "Requires participation in a declared contract or module by the patient, provider, or practice.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "reject"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "contract-participation"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "accompanying-information-required",
"display" : "Accompanying information required",
"definition" : "Requires declared structured information, justification, report, or itemized cost evidence.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "requires-justification"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "accompanying-information"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "prior-authorization-required",
"display" : "Prior authorization required",
"definition" : "Requires an approved plan or authorization before the service is rendered or billed.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "requires-approval"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "prior-authorization"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "patient-agreement-required",
"display" : "Patient agreement required",
"definition" : "Requires a declared patient agreement before billing under the stated conditions.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "requires-agreement"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "patient-agreement"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "factor-bound",
"display" : "Factor bound",
"definition" : "Applies declared multiplier bounds and maps threshold crossings to a declared effect.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "requires-justification"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "billing-factor"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "analogue-service",
"display" : "Analogue service",
"definition" : "Constrains billing of an unlisted service by reference to a declared equivalent listed service.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "requires-justification"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "analogue-reference"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "cost-reimbursement-constraint",
"display" : "Cost reimbursement constraint",
"definition" : "Constrains material or laboratory cost reimbursement using declared evidence requirements or limits.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "requires-justification"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "cost-evidence"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "quota-degression",
"display" : "Quota degression",
"definition" : "Applies a declared reduced valuation after a volume threshold is exceeded.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "price-adjust"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "volume"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "service-value"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
},
{
"code" : "plan-finding-entitlement",
"display" : "Plan and finding entitlement",
"definition" : "Derives a permitted treatment path or subsidy from declared findings and an approved plan.",
"property" : [
{
"code" : "defaultEffect",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect",
"code" : "price-adjust"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "approved-plan"
}
},
{
"code" : "requiredFactTypes",
"valueCoding" : {
"system" : "https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact",
"code" : "finding"
}
},
{
"code" : "since",
"valueString" : "1"
}
]
}
]
}
