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

ValueSet: Cross-version VS for R5.ClaimAdjudicationDecisionReasonCodes for use in FHIR R4

Official URL: http://hl7.org/fhir/5.0/ValueSet/R5-claim-decision-reason-for-R4 Version: 0.0.1-snapshot-2
Standards status: Informative Maturity Level: 1 Responsible: Financial Management Computable Name: R5_claim_decision_reason_for_R4

This cross-version ValueSet represents concepts from http://hl7.org/fhir/ValueSet/claim-decision-reason 5.0.0 for use in FHIR R4. Concepts not present here have direct equivalent mappings crossing all versions from R5 to R4.

References

Logical Definition (CLD)

  • Include these codes as defined in http://hl7.org/fhir/claim-decision-reason version 5.0.0
    CodeDisplayDefinition
    0001Not medically necessaryThe payer has determined this product, service, or procedure as not medically necessary.
    0002Prior authorization not obtainedPrior authorization was not obtained prior to providing the product, service, or procedure.
    0003Provider out-of-networkThis provider is considered out-of-network by the payer for this plan.
    0004Service inconsistent with patient ageThe payer has determined this product, service, or procedure is not consistent with the patient's age.
    0005Benefit limits exceededThe patient or subscriber benefit's have been exceeded.

 

Expansion

This value set expansion contains 5 concepts.

CodeSystemDisplayDefinition
  0001http://hl7.org/fhir/claim-decision-reasonNot medically necessaryThe payer has determined this product, service, or procedure as not medically necessary.
  0002http://hl7.org/fhir/claim-decision-reasonPrior authorization not obtainedPrior authorization was not obtained prior to providing the product, service, or procedure.
  0003http://hl7.org/fhir/claim-decision-reasonProvider out-of-networkThis provider is considered out-of-network by the payer for this plan.
  0004http://hl7.org/fhir/claim-decision-reasonService inconsistent with patient ageThe payer has determined this product, service, or procedure is not consistent with the patient's age.
  0005http://hl7.org/fhir/claim-decision-reasonBenefit limits exceededThe patient or subscriber benefit's have been exceeded.

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System 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)
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