FHIR IG analytics| Package | hl7.fhir.uv.xver-r5.r4.r4 |
| Resource Type | ValueSet |
| Id | ValueSet-R5-claim-decision-reason-for-R4.json |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/uv/xver-r5.r4/0.0.1-snapshot-2/ValueSet-R5-claim-decision-reason-for-R4.html |
| URL | http://hl7.org/fhir/5.0/ValueSet/R5-claim-decision-reason-for-R4 |
| Version | 0.0.1-snapshot-2 |
| Status | active |
| Date | 2025-09-01T22:37:02.022609+10:00 |
| Name | R5_claim_decision_reason_for_R4 |
| Title | Cross-version VS for R5.ClaimAdjudicationDecisionReasonCodes for use in FHIR R4 |
| Realm | uv |
| Authority | hl7 |
| Description | This cross-version ValueSet represents concepts from http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0 for use in FHIR R4. Concepts not present here have direct `equivalent` mappings crossing all versions from R5 to R4. |
No resources found
| CodeSystem | |
| claim-decision-reason | Claim Adjudication Decision Reason Codes |
Note: links and images are rebased to the (stated) source
Generated Narrative: ValueSet R5-claim-decision-reason-for-R4
This value set expansion contains 5 concepts.
| Code | System | Display | Definition |
| 0001 | http://hl7.org/fhir/claim-decision-reason | Not medically necessary | The payer has determined this product, service, or procedure as not medically necessary. |
| 0002 | http://hl7.org/fhir/claim-decision-reason | Prior authorization not obtained | Prior authorization was not obtained prior to providing the product, service, or procedure. |
| 0003 | http://hl7.org/fhir/claim-decision-reason | Provider out-of-network | This provider is considered out-of-network by the payer for this plan. |
| 0004 | http://hl7.org/fhir/claim-decision-reason | Service inconsistent with patient age | The payer has determined this product, service, or procedure is not consistent with the patient's age. |
| 0005 | http://hl7.org/fhir/claim-decision-reason | Benefit limits exceeded | The patient or subscriber benefit's have been exceeded. |
FHIR
FHIRsmith{
"resourceType": "ValueSet",
"id": "R5-claim-decision-reason-for-R4",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"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": "0.0.1-snapshot-2"
}
],
"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/5.0/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"
}
]
}
}
],
"url": "http://hl7.org/fhir/5.0/ValueSet/R5-claim-decision-reason-for-R4",
"version": "0.0.1-snapshot-2",
"name": "R5_claim_decision_reason_for_R4",
"title": "Cross-version VS for R5.ClaimAdjudicationDecisionReasonCodes for use in FHIR R4",
"status": "active",
"experimental": false,
"date": "2025-09-01T22:37:02.022609+10:00",
"publisher": "Financial Management",
"contact": [
{
"name": "Financial Management",
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm"
}
]
}
],
"description": "This cross-version ValueSet represents concepts from http://hl7.org/fhir/ValueSet/claim-decision-reason|5.0.0 for use in FHIR R4. Concepts not present here have direct `equivalent` mappings crossing all versions from R5 to R4.",
"jurisdiction": [
{
"coding": [
{
"system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
"code": "001",
"display": "World"
}
]
}
],
"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": "2025-09-01T22:37:02.022606+10:00",
"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"
}
]
}
}