FHIR Cross-Version Extensions package for FHIR R4 from FHIR R5
0.0.1-snapshot-2 - informative International flag

FHIR Cross-Version Extensions package for FHIR R4 from FHIR R5 - Version 0.0.1-snapshot-2. See the Directory of published versions

CodeSystem: Claim Adjudication Decision Reason Codes

Official URL: http://hl7.org/fhir/claim-decision-reason Version: 5.0.0
Standards status: Informative Maturity Level: 0 Responsible: Financial Management Computable Name: ClaimAdjudicationDecisionReasonCodes

Copyright/Legal: HL7 Inc.

This value set provides example Claim Adjudication Decision Reason codes.

This Code system is referenced in the content logical definition of the following value sets:

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

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