Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions

4.3.2.211 CodeSystem http://hl7.org/fhir/claim-decision-reason

Financial Management icon Work Group Maturity Level: 0Informative Use Context: Country: World
Official URL: http://hl7.org/fhir/claim-decision-reason Version: 5.0.0
active as of 2023-03-26 Computable Name: ClaimAdjudicationDecisionReasonCodes
Flags: CaseSensitive, Complete OID: TBD

This Code system is used in the following value sets:

4.3.2.211.1 Definition

This value set provides example Claim Adjudication Decision Reason codes.

4.3.2.211.2 Content

This code system http://hl7.org/fhir/claim-decision-reason defines the following codes:

CodeDisplayDefinitionCopy
0001 Not medically necessaryThe payer has determined this product, service, or procedure as not medically necessary.btn btn
0002 Prior authorization not obtainedPrior authorization was not obtained prior to providing the product, service, or procedure.btn btn
0003 Provider out-of-networkThis provider is considered out-of-network by the payer for this plan.btn btn
0004 Service inconsistent with patient ageThe payer has determined this product, service, or procedure is not consistent with the patient's age.btn btn
0005 Benefit limits exceededThe patient or subscriber benefit's have been exceeded.btn btn

 

See the full registry of code systems defined as part of FHIR.

Explanation of the columns that may appear on this page:

LevelA few code lists that FHIR defines are hierarchical - each code is assigned a level. See Code System for further information.
SourceThe source of the definition of the code (when the value set draws in codes defined elsewhere)
CodeThe code (used as the code in the resource instance). If the code is in italics, this indicates that the code is not selectable ('Abstract')
DisplayThe 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
DefinitionAn explanation of the meaning of the concept
CommentsAdditional notes about how to use the code