Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

4.4.1.321 ValueSet http://hl7.org/fhir/ValueSet/claim-decision-reason

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Work Group

Maturity Level: 1

Draft

Use Context: Country: World, Not Intended for Production use

Official URL: `http://hl7.org/fhir/ValueSet/claim-decision-reason`				Version: 5.0.0
draft as of 2023-03-26				Computable Name: ClaimAdjudicationDecisionReasonCodes
Flags: Experimental				OID:

This value set is used in the following places:

Resource: ExplanationOfBenefit.item.reviewOutcome.reason (CodeableConcept / Example)
Resource: ClaimResponse.item.reviewOutcome.reason (CodeableConcept / Example)

4.4.1.321.1 Definition

This value set includes example Claim Adjudication Decision Reason codes.

4.4.1.321.2 Content Logical Definition

Include all codes defined in http://hl7.org/fhir/claim-decision-reason

4.4.1.321.3 Expansion

This expansion generated 26 Mar 2023

This value set contains 5 concepts

Expansion based on Claim Adjudication Decision Reason Codes v5.0.0 (CodeSystem)

Code	System	Display	Definition
0001	http://hl7.org/fhir/claim-decision-reason	Not medically necessary	The payer has determined this product, service, or procedure as not medically necessary.
0002	http://hl7.org/fhir/claim-decision-reason	Prior authorization not obtained	Prior authorization was not obtained prior to providing the product, service, or procedure.
0003	http://hl7.org/fhir/claim-decision-reason	Provider out-of-network	This provider is considered out-of-network by the payer for this plan.
0004	http://hl7.org/fhir/claim-decision-reason	Service inconsistent with patient age	The payer has determined this product, service, or procedure is not consistent with the patient's age.
0005	http://hl7.org/fhir/claim-decision-reason	Benefit limits exceeded	The patient or subscriber benefit's have been exceeded.

See the full registry of value sets defined as part of FHIR.

Explanation of the columns that may appear on this page:

Lvl

A few code lists that FHIR defines are hierarchical - each code is assigned a level. For value sets, levels are mostly used to organize codes for user convenience, but may follow code system hierarchy - see Code System for further information

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). If the code is in italics, this indicates that the code is not selectable ('Abstract')

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