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Source1

{
  "resourceType": "CodeSystem",
  "id": "claim-decision-reason",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "extension": [
        {
          "url": "packageId",
          "valueId": "hl7.fhir.uv.xver-r5.r4b"
        },
        {
          "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": "2025-09-13T17:27:08-04:00",
  "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."
    }
  ]
}