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Packagehl7.fhir.uv.xver-r5.r4.r4b
Resource TypeCodeSystem
IdCodeSystem-claim-decision-reason.json
FHIR VersionR4B

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Narrative

Note: links and images are rebased to the (stated) source

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

Code Display Definition
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.

Source1

{
  "resourceType": "CodeSystem",
  "id": "claim-decision-reason",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "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-wg",
      "valueCode": "fm"
    }
  ],
  "url": "http://hl7.org/fhir/claim-decision-reason",
  "version": "5.0.0",
  "name": "ClaimAdjudicationDecisionReasonCodes",
  "title": "Claim Adjudication Decision Reason Codes",
  "status": "active",
  "experimental": false,
  "date": "2025-09-13T16:55:28-04:00",
  "publisher": "Financial Management",
  "contact": [
    {
      "name": "Financial Management",
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "description": "This value set provides example Claim Adjudication Decision Reason codes.",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code": "001",
          "display": "World"
        }
      ]
    }
  ],
  "copyright": "HL7 Inc.",
  "caseSensitive": true,
  "content": "complete",
  "concept": [
    {
      "code": "0001",
      "display": "Not medically necessary",
      "definition": "The payer has determined this product, service, or procedure as not medically necessary."
    },
    {
      "code": "0002",
      "display": "Prior authorization not obtained",
      "definition": "Prior authorization was not obtained prior to providing the product, service, or procedure."
    },
    {
      "code": "0003",
      "display": "Provider out-of-network",
      "definition": "This provider is considered out-of-network by the payer for this plan."
    },
    {
      "code": "0004",
      "display": "Service inconsistent with patient age",
      "definition": "The payer has determined this product, service, or procedure is not consistent with the patient's age."
    },
    {
      "code": "0005",
      "display": "Benefit limits exceeded",
      "definition": "The patient or subscriber benefit's have been exceeded."
    }
  ]
}