Extensions for Using Data Elements from FHIR R5 in FHIR R4
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Extensions for Using Data Elements from FHIR R5 in FHIR R4 - Downloaded Version null See the Directory of published versions

: R5ClaimDecisionReasonForR4 - XML Representation

Page standards status: Trial-use 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><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">  <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">  <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">  <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">  <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">  <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>
  </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="0.1.0"/>
    </extension>
    <extension url="uri">
      <valueUri
                value="http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="trial-use">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/uv/xver/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/uv/xver/ValueSet/R5-claim-decision-reason-for-R4"/>
  <version value="0.1.0"/>
  <name value="R5ClaimDecisionReasonForR4"/>
  <title
         value="Cross-version ValueSet R5.ClaimAdjudicationDecisionReasonCodes for use in FHIR R4"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2026-03-17T21:02:03.8104715+00:00"/>
  <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 content from `http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0` for use in FHIR R4."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <purpose
           value="This value set is part of the cross-version definitions generated to enable use of the
value set `http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0` as defined in FHIR R5
in FHIR R4.

The source value set is bound to the following FHIR R5 elements:
* `ClaimResponse.item.reviewOutcome.reason`
* `ExplanationOfBenefit.item.reviewOutcome.reason`

Note that all concepts are included in this cross-version definition because no concepts have compatible representations

Following are the generation technical comments:

FHIR 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 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="2026-03-17T21:02:03.8104715+00:00"/>
    <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>