FHIR Cross-Version Extensions package for FHIR R4 from FHIR R5 - Version 0.0.1-snapshot-2. See the Directory of published versions

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: Claim Adjudication Decision Reason Codes - XML Representation

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<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="claim-decision-reason"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
            <p>This code system 
              <code>http://hl7.org/fhir/claim-decision-reason</code> defines the following codes:
            </p>
            <table class="codes">
              <tr>
                <td style="white-space:nowrap">
                  <b>Code</b>
                </td>
                <td>
                  <b>Display</b>
                </td>
                <td>
                  <b>Definition</b>
                </td>
              </tr>
              <tr>
                <td style="white-space:nowrap">0001
                  <a name="claim-decision-reason-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 style="white-space:nowrap">0002
                  <a name="claim-decision-reason-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 style="white-space:nowrap">0003
                  <a name="claim-decision-reason-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 style="white-space:nowrap">0004
                  <a name="claim-decision-reason-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 style="white-space:nowrap">0005
                  <a name="claim-decision-reason-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/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-wg">
    <valueCode value="fm"/>
  </extension>
  <url value="http://hl7.org/fhir/claim-decision-reason"/>
  <version value="5.0.0"/>
  <name value="ClaimAdjudicationDecisionReasonCodes"/>
  <title value="Claim Adjudication Decision Reason Codes"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2025-09-13T16:55:28-04:00"/>
  <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 value set provides example Claim Adjudication Decision Reason codes."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <copyright value="HL7 Inc."/>
  <caseSensitive value="true"/>
  <content value="complete"/>
  <concept>
    <code value="0001"/>
    <display value="Not medically necessary"/>
    <definition
                value="The payer has determined this product, service, or procedure as not medically necessary."/>
  </concept>
  <concept>
    <code value="0002"/>
    <display value="Prior authorization not obtained"/>
    <definition
                value="Prior authorization was not obtained prior to providing the product, service, or procedure."/>
  </concept>
  <concept>
    <code value="0003"/>
    <display value="Provider out-of-network"/>
    <definition
                value="This provider is considered out-of-network by the payer for this plan."/>
  </concept>
  <concept>
    <code value="0004"/>
    <display value="Service inconsistent with patient age"/>
    <definition
                value="The payer has determined this product, service, or procedure is not consistent with the patient's age."/>
  </concept>
  <concept>
    <code value="0005"/>
    <display value="Benefit limits exceeded"/>
    <definition
                value="The patient or subscriber benefit's have been exceeded."/>
  </concept>
</CodeSystem>