R6 Ballot (1st Draft)

This page is part of the FHIR Specification v6.0.0-ballot1: Release 6 Ballot (1st Draft) (see Ballot Notes). The current version is 5.0.0. For a full list of available versions, see the Directory of published versions

4.3.2.217 CodeSystem http://hl7.org/fhir/claim-decision-reason

Financial Management icon

Work Group

Maturity Level: 0

Informative

Use Context: Country: World

Official URL: `http://hl7.org/fhir/claim-decision-reason`				Version: 6.0.0-ballot1
active as of 2023-12-18				Computable Name: ClaimAdjudicationDecisionReasonCodes
Flags: CaseSensitive, Complete				OID: TBD

This Code system is used in the following value sets:

ValueSet: Claim Adjudication Decision Reason Codes (This value set includes example Claim Adjudication Decision Reason codes.)

4.3.2.217.1 Definition

This value set provides example Claim Adjudication Decision Reason codes.

4.3.2.217.2 Content

This case-sensitive code system http://hl7.org/fhir/claim-decision-reason defines the following codes:

Code	Display	Definition	Copy
0001	Not medically necessary	The payer has determined this product, service, or procedure as not medically necessary.
0002	Prior authorization not obtained	Prior authorization was not obtained prior to providing the product, service, or procedure.
0003	Provider out-of-network	This provider is considered out-of-network by the payer for this plan.
0004	Service inconsistent with patient age	The payer has determined this product, service, or procedure is not consistent with the patient's age.
0005	Benefit limits exceeded	The patient or subscriber benefit's have been exceeded.

See the full registry of code systems defined as part of FHIR.

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. See Code System for further information.

Source

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). If the code is in italics, this indicates that the code is not selectable ('Abstract')

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