: Billing Rule Class - XML Representation
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<CodeSystem xmlns="http://hl7.org/fhir">
<id value="billing-rule-class"/>
<text>
<status value="generated"/>
<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>
</text>
<url value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class"/>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:oid:2.16.840.1.113883.3.7985.16.20"/>
</identifier>
<version value="1"/>
<name value="BillingRuleClassCS"/>
<title value="Billing Rule Class"/>
<status value="active"/>
<experimental value="false"/>
<date value="2026-08-22T18:18:46+02:00"/>
<publisher value="cognovis GmbH"/>
<contact>
<name value="cognovis GmbH"/>
<telecom>
<system value="url"/>
<value value="https://www.cognovis.de"/>
</telecom>
<telecom>
<system value="email"/>
<value value="info@cognovis.de"/>
</telecom>
</contact>
<description
value="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 value="urn:iso:std:iso:3166"/>
<code value="DE"/>
</coding>
</jurisdiction>
<copyright
value="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 value="true"/>
<content value="complete"/>
<count value="20"/>
<property>
<code value="defaultEffect"/>
<uri
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#defaultEffect"/>
<description
value="Default effect when a rule instance does not declare a more specific supported effect"/>
<type value="Coding"/>
</property>
<property>
<code value="requiredFactTypes"/>
<uri
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#requiredFactTypes"/>
<description
value="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 value="Coding"/>
</property>
<property>
<code value="since"/>
<uri
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#since"/>
<description
value="Semantic major in which this immutable class concept was introduced"/>
<type value="string"/>
</property>
<property>
<code value="replacedBy"/>
<uri
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-class#replacedBy"/>
<description
value="Successor class concept when this concept is retired"/>
<type value="Coding"/>
</property>
<concept>
<code value="quantity-limit"/>
<display value="Quantity limit"/>
<definition
value="Limits the number of matching services within a counting scope."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-occurrence"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="value-limit"/>
<display value="Value limit"/>
<definition
value="Limits the sum of a measure, such as currency, points, or minutes, within a counting scope."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-value"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="mutual-exclusion"/>
<display value="Mutual exclusion"/>
<definition
value="Forbids selected services from occurring together within a counting scope."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-occurrence"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="inclusive-component"/>
<display value="Inclusive component"/>
<definition
value="Declares that a component service is included in a containing service and is not separately billable in the stated direction."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-occurrence"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="companion-required"/>
<display value="Companion required"/>
<definition
value="Requires one or more companion services, optionally with ordering constraints, within a counting scope."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-occurrence"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="repeat-interval"/>
<display value="Repeat interval"/>
<definition
value="Requires a minimum interval before a matching service may be repeated for the same counting subject."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-occurrence"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="diagnosis-requirement"/>
<display value="Diagnosis requirement"/>
<definition
value="Requires or forbids a diagnosis matching a declared selector, certainty, and time window."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="diagnosis"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="procedure-finding-requirement"/>
<display value="Procedure or finding requirement"/>
<definition
value="Requires a documented procedure, finding, or measurement matching the declared selector."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="procedure"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="finding"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="patient-attribute-constraint"/>
<display value="Patient attribute constraint"/>
<definition
value="Constrains applicability using declared patient demographic or status predicates."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="patient-attribute"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="provider-eligibility"/>
<display value="Provider eligibility"/>
<definition
value="Constrains applicability using declared provider specialty, authorization, or relationship predicates."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="provider-eligibility"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="setting-constraint"/>
<display value="Setting constraint"/>
<definition
value="Constrains applicability using declared care setting, billing case, place, time, or treatment-kind predicates."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="care-setting"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="contract-participation"/>
<display value="Contract participation"/>
<definition
value="Requires participation in a declared contract or module by the patient, provider, or practice."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="reject"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="contract-participation"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="accompanying-information-required"/>
<display value="Accompanying information required"/>
<definition
value="Requires declared structured information, justification, report, or itemized cost evidence."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="requires-justification"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="accompanying-information"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="prior-authorization-required"/>
<display value="Prior authorization required"/>
<definition
value="Requires an approved plan or authorization before the service is rendered or billed."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="requires-approval"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="prior-authorization"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="patient-agreement-required"/>
<display value="Patient agreement required"/>
<definition
value="Requires a declared patient agreement before billing under the stated conditions."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="requires-agreement"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="patient-agreement"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="factor-bound"/>
<display value="Factor bound"/>
<definition
value="Applies declared multiplier bounds and maps threshold crossings to a declared effect."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="requires-justification"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="billing-factor"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="analogue-service"/>
<display value="Analogue service"/>
<definition
value="Constrains billing of an unlisted service by reference to a declared equivalent listed service."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="requires-justification"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="analogue-reference"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="cost-reimbursement-constraint"/>
<display value="Cost reimbursement constraint"/>
<definition
value="Constrains material or laboratory cost reimbursement using declared evidence requirements or limits."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="requires-justification"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="cost-evidence"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="quota-degression"/>
<display value="Quota degression"/>
<definition
value="Applies a declared reduced valuation after a volume threshold is exceeded."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="price-adjust"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="volume"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="service-value"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
<concept>
<code value="plan-finding-entitlement"/>
<display value="Plan and finding entitlement"/>
<definition
value="Derives a permitted treatment path or subsidy from declared findings and an approved plan."/>
<property>
<code value="defaultEffect"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-rule-effect"/>
<code value="price-adjust"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="approved-plan"/>
</valueCoding>
</property>
<property>
<code value="requiredFactTypes"/>
<valueCoding>
<system
value="https://fhir.cognovis.de/praxis/CodeSystem/billing-required-fact"/>
<code value="finding"/>
</valueCoding>
</property>
<property>
<code value="since"/>
<valueString value="1"/>
</property>
</concept>
</CodeSystem>
