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

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

Page standards status: Informative Maturity Level: 1

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<ValueSet xmlns="http://hl7.org/fhir">
  <id value="R5-claim-decision-reason-for-R4"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ValueSet R5-claim-decision-reason-for-R4</b></p><a name="R5-claim-decision-reason-for-R4"> </a><a name="hcR5-claim-decision-reason-for-R4"> </a><p>This value set expansion contains 5 concepts.</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>System</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap"><a name="R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0001"> </a>  <a href="CodeSystem-claim-decision-reason.html#claim-decision-reason-0001">0001</a></td><td>http://hl7.org/fhir/claim-decision-reason</td><td>Not medically necessary</td><td>The payer has determined this product, service, or procedure as not medically necessary.</td></tr><tr><td style="white-space:nowrap"><a name="R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0002"> </a>  <a href="CodeSystem-claim-decision-reason.html#claim-decision-reason-0002">0002</a></td><td>http://hl7.org/fhir/claim-decision-reason</td><td>Prior authorization not obtained</td><td>Prior authorization was not obtained prior to providing the product, service, or procedure.</td></tr><tr><td style="white-space:nowrap"><a name="R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0003"> </a>  <a href="CodeSystem-claim-decision-reason.html#claim-decision-reason-0003">0003</a></td><td>http://hl7.org/fhir/claim-decision-reason</td><td>Provider out-of-network</td><td>This provider is considered out-of-network by the payer for this plan.</td></tr><tr><td style="white-space:nowrap"><a name="R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0004"> </a>  <a href="CodeSystem-claim-decision-reason.html#claim-decision-reason-0004">0004</a></td><td>http://hl7.org/fhir/claim-decision-reason</td><td>Service inconsistent with patient age</td><td>The payer has determined this product, service, or procedure is not consistent with the patient's age.</td></tr><tr><td style="white-space:nowrap"><a name="R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0005"> </a>  <a href="CodeSystem-claim-decision-reason.html#claim-decision-reason-0005">0005</a></td><td>http://hl7.org/fhir/claim-decision-reason</td><td>Benefit limits exceeded</td><td>The patient or subscriber benefit's have been exceeded.</td></tr></table></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
    <valueInteger value="1"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fm"/>
  </extension>
  <extension url="http://hl7.org/fhir/StructureDefinition/package-source">
    <extension url="packageId">
      <valueId value="hl7.fhir.uv.xver-r5.r4"/>
    </extension>
    <extension url="version">
      <valueString value="0.0.1-snapshot-2"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="informative">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/5.0/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/5.0/ValueSet/R5-claim-decision-reason-for-R4"/>
  <version value="0.0.1-snapshot-2"/>
  <name value="R5_claim_decision_reason_for_R4"/>
  <title
         value="Cross-version VS for R5.ClaimAdjudicationDecisionReasonCodes for use in FHIR R4"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2025-09-01T22:37:02.022609+10:00"/>
  <publisher value="Financial Management"/>
  <contact>
    <name value="Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
  </contact>
  <description
               value="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."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <compose>
    <include>
      <system value="http://hl7.org/fhir/claim-decision-reason"/>
      <version value="5.0.0"/>
      <concept>
        <code value="0001"/>
        <display value="Not medically necessary"/>
      </concept>
      <concept>
        <code value="0002"/>
        <display value="Prior authorization not obtained"/>
      </concept>
      <concept>
        <code value="0003"/>
        <display value="Provider out-of-network"/>
      </concept>
      <concept>
        <code value="0004"/>
        <display value="Service inconsistent with patient age"/>
      </concept>
      <concept>
        <code value="0005"/>
        <display value="Benefit limits exceeded"/>
      </concept>
    </include>
  </compose>
  <expansion>
    <timestamp value="2025-09-01T22:37:02.022606+10:00"/>
    <contains>
      <system value="http://hl7.org/fhir/claim-decision-reason"/>
      <version value="5.0.0"/>
      <code value="0001"/>
      <display value="Not medically necessary"/>
    </contains>
    <contains>
      <system value="http://hl7.org/fhir/claim-decision-reason"/>
      <version value="5.0.0"/>
      <code value="0002"/>
      <display value="Prior authorization not obtained"/>
    </contains>
    <contains>
      <system value="http://hl7.org/fhir/claim-decision-reason"/>
      <version value="5.0.0"/>
      <code value="0003"/>
      <display value="Provider out-of-network"/>
    </contains>
    <contains>
      <system value="http://hl7.org/fhir/claim-decision-reason"/>
      <version value="5.0.0"/>
      <code value="0004"/>
      <display value="Service inconsistent with patient age"/>
    </contains>
    <contains>
      <system value="http://hl7.org/fhir/claim-decision-reason"/>
      <version value="5.0.0"/>
      <code value="0005"/>
      <display value="Benefit limits exceeded"/>
    </contains>
  </expansion>
</ValueSet>