Extensions for Using Data Elements from FHIR R5 in FHIR R4B
0.1.0 - STU International flag

Extensions for Using Data Elements from FHIR R5 in FHIR R4B - Downloaded Version null See the Directory of published versions

ValueSet: R5ClaimDecisionReasonForR4B

Official URL: http://hl7.org/fhir/uv/xver/ValueSet/R5-claim-decision-reason-for-R4B Version: 0.1.0
Standards status: Trial-use Maturity Level: 1 Responsible: Financial Management Computable Name: R5ClaimDecisionReasonForR4B

This cross-version ValueSet represents content from http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0 for use in FHIR R4B.

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 R4B.

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 R4B

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.

SystemVersionCodeDisplayDefinitionJSONXML
http://hl7.org/fhir/claim-decision-reason5.0.0  0001Not medically necessaryThe payer has determined this product, service, or procedure as not medically necessary.
http://hl7.org/fhir/claim-decision-reason5.0.0  0002Prior authorization not obtainedPrior authorization was not obtained prior to providing the product, service, or procedure.
http://hl7.org/fhir/claim-decision-reason5.0.0  0003Provider out-of-networkThis provider is considered out-of-network by the payer for this plan.
http://hl7.org/fhir/claim-decision-reason5.0.0  0004Service inconsistent with patient ageThe payer has determined this product, service, or procedure is not consistent with the patient's age.
http://hl7.org/fhir/claim-decision-reason5.0.0  0005Benefit 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