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

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: Claim Adjudication Decision Reason Codes - JSON Representation

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{
  "resourceType" : "CodeSystem",
  "id" : "claim-decision-reason",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n            <p>This code system \n              <code>http://hl7.org/fhir/claim-decision-reason</code> defines the following codes:\n            </p>\n            <table class=\"codes\">\n              <tr>\n                <td style=\"white-space:nowrap\">\n                  <b>Code</b>\n                </td>\n                <td>\n                  <b>Display</b>\n                </td>\n                <td>\n                  <b>Definition</b>\n                </td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0001\n                  <a name=\"claim-decision-reason-0001\"> </a>\n                </td>\n                <td>Not medically necessary</td>\n                <td>The payer has determined this product, service, or procedure as not medically necessary.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0002\n                  <a name=\"claim-decision-reason-0002\"> </a>\n                </td>\n                <td>Prior authorization not obtained</td>\n                <td>Prior authorization was not obtained prior to providing the product, service, or procedure.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0003\n                  <a name=\"claim-decision-reason-0003\"> </a>\n                </td>\n                <td>Provider out-of-network</td>\n                <td>This provider is considered out-of-network by the payer for this plan.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0004\n                  <a name=\"claim-decision-reason-0004\"> </a>\n                </td>\n                <td>Service inconsistent with patient age</td>\n                <td>The payer has determined this product, service, or procedure is not consistent with the patient's age.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0005\n                  <a name=\"claim-decision-reason-0005\"> </a>\n                </td>\n                <td>Benefit limits exceeded</td>\n                <td>The patient or subscriber benefit's have been exceeded.</td>\n              </tr>\n            </table>\n          </div>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "packageId",
          "valueId" : "hl7.fhir.uv.xver-r5.r4"
        },
        {
          "url" : "version",
          "valueString" : "0.0.1-snapshot-2"
        }
      ],
      "url" : "http://hl7.org/fhir/StructureDefinition/package-source"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "fm"
    }
  ],
  "url" : "http://hl7.org/fhir/claim-decision-reason",
  "version" : "5.0.0",
  "name" : "ClaimAdjudicationDecisionReasonCodes",
  "title" : "Claim Adjudication Decision Reason Codes",
  "status" : "active",
  "experimental" : false,
  "date" : "2025-09-13T16:55:28-04:00",
  "publisher" : "Financial Management",
  "contact" : [
    {
      "name" : "Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "description" : "This value set provides example Claim Adjudication Decision Reason codes.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code" : "001",
          "display" : "World"
        }
      ]
    }
  ],
  "copyright" : "HL7 Inc.",
  "caseSensitive" : true,
  "content" : "complete",
  "concept" : [
    {
      "code" : "0001",
      "display" : "Not medically necessary",
      "definition" : "The payer has determined this product, service, or procedure as not medically necessary."
    },
    {
      "code" : "0002",
      "display" : "Prior authorization not obtained",
      "definition" : "Prior authorization was not obtained prior to providing the product, service, or procedure."
    },
    {
      "code" : "0003",
      "display" : "Provider out-of-network",
      "definition" : "This provider is considered out-of-network by the payer for this plan."
    },
    {
      "code" : "0004",
      "display" : "Service inconsistent with patient age",
      "definition" : "The payer has determined this product, service, or procedure is not consistent with the patient's age."
    },
    {
      "code" : "0005",
      "display" : "Benefit limits exceeded",
      "definition" : "The patient or subscriber benefit's have been exceeded."
    }
  ]
}