{
  "resourceType" : "ValueSet",
  "id" : "R5-claim-decision-reason-for-R4",
  "text" : {
    "status" : "generated",
    "div" : "<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><b>System</b></td><td><b>Version</b></td><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a name=\"R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0001\"> </a><code>http://hl7.org/fhir/claim-decision-reason</code></td><td>5.0.0</td><td style=\"white-space:nowrap\">\u00a0\u00a0<a href=\"CodeSystem-claim-decision-reason.html#claim-decision-reason-0001\">0001</a></td><td>Not medically necessary</td><td>The payer has determined this product, service, or procedure as not medically necessary.</td></tr><tr><td><a name=\"R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0002\"> </a><code>http://hl7.org/fhir/claim-decision-reason</code></td><td>5.0.0</td><td style=\"white-space:nowrap\">\u00a0\u00a0<a href=\"CodeSystem-claim-decision-reason.html#claim-decision-reason-0002\">0002</a></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><a name=\"R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0003\"> </a><code>http://hl7.org/fhir/claim-decision-reason</code></td><td>5.0.0</td><td style=\"white-space:nowrap\">\u00a0\u00a0<a href=\"CodeSystem-claim-decision-reason.html#claim-decision-reason-0003\">0003</a></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><a name=\"R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0004\"> </a><code>http://hl7.org/fhir/claim-decision-reason</code></td><td>5.0.0</td><td style=\"white-space:nowrap\">\u00a0\u00a0<a href=\"CodeSystem-claim-decision-reason.html#claim-decision-reason-0004\">0004</a></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><a name=\"R5-claim-decision-reason-for-R4-http://hl7.org/fhir/claim-decision-reason-0005\"> </a><code>http://hl7.org/fhir/claim-decision-reason</code></td><td>5.0.0</td><td style=\"white-space:nowrap\">\u00a0\u00a0<a href=\"CodeSystem-claim-decision-reason.html#claim-decision-reason-0005\">0005</a></td><td>Benefit limits exceeded</td><td>The patient or subscriber benefit's have been exceeded.</td></tr></table></div>"
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 1
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "fm"
  },
  {
    "extension" : [{
      "url" : "packageId",
      "valueId" : "hl7.fhir.uv.xver-r5.r4"
    },
    {
      "url" : "version",
      "valueString" : "0.1.0"
    },
    {
      "url" : "uri",
      "valueUri" : "http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"
    }],
    "url" : "http://hl7.org/fhir/StructureDefinition/package-source"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/uv/xver/ValueSet/R5-claim-decision-reason-for-R4",
  "version" : "0.1.0",
  "name" : "R5ClaimDecisionReasonForR4",
  "title" : "Cross-version ValueSet R5.ClaimAdjudicationDecisionReasonCodes for use in FHIR R4",
  "status" : "active",
  "experimental" : false,
  "date" : "2026-03-17T21:02:03.8104715+00:00",
  "publisher" : "Financial Management",
  "contact" : [{
    "name" : "Financial Management",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/fm"
    }]
  }],
  "description" : "This cross-version ValueSet represents content from `http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0` for use in FHIR R4.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "code" : "001",
      "display" : "World"
    }]
  }],
  "purpose" : "This value set is part of the cross-version definitions generated to enable use of the\r\nvalue set `http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0` as defined in FHIR R5\r\nin FHIR R4.\r\n\r\nThe source value set is bound to the following FHIR R5 elements:\r\n* `ClaimResponse.item.reviewOutcome.reason`\n* `ExplanationOfBenefit.item.reviewOutcome.reason`\r\n\r\nNote that all concepts are included in this cross-version definition because no concepts have compatible representations\r\n\r\nFollowing are the generation technical comments:\r\n\nFHIR ValueSet `http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0`, defined in FHIR R5 does not have any mapping to FHIR R4",
  "compose" : {
    "include" : [{
      "system" : "http://hl7.org/fhir/claim-decision-reason",
      "version" : "5.0.0",
      "concept" : [{
        "code" : "0001",
        "display" : "Not medically necessary"
      },
      {
        "code" : "0002",
        "display" : "Prior authorization not obtained"
      },
      {
        "code" : "0003",
        "display" : "Provider out-of-network"
      },
      {
        "code" : "0004",
        "display" : "Service inconsistent with patient age"
      },
      {
        "code" : "0005",
        "display" : "Benefit limits exceeded"
      }]
    }]
  },
  "expansion" : {
    "timestamp" : "2026-03-17T21:02:03.8104715+00:00",
    "contains" : [{
      "system" : "http://hl7.org/fhir/claim-decision-reason",
      "version" : "5.0.0",
      "code" : "0001",
      "display" : "Not medically necessary"
    },
    {
      "system" : "http://hl7.org/fhir/claim-decision-reason",
      "version" : "5.0.0",
      "code" : "0002",
      "display" : "Prior authorization not obtained"
    },
    {
      "system" : "http://hl7.org/fhir/claim-decision-reason",
      "version" : "5.0.0",
      "code" : "0003",
      "display" : "Provider out-of-network"
    },
    {
      "system" : "http://hl7.org/fhir/claim-decision-reason",
      "version" : "5.0.0",
      "code" : "0004",
      "display" : "Service inconsistent with patient age"
    },
    {
      "system" : "http://hl7.org/fhir/claim-decision-reason",
      "version" : "5.0.0",
      "code" : "0005",
      "display" : "Benefit limits exceeded"
    }]
  }
}