R6 Ballot (3rd Draft) FHIR CI-Build

This page is part of the FHIR Specification v6.0.0-ballot3: Release 6 Ballot (3rd Draft) (see Ballot Notes ). The current version is 5.0.0 . For a full list Continuous Integration Build of available versions, see FHIR (will be incorrect/inconsistent at times).
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4.3.2.219 4.3.2.206 CodeSystem http://hl7.org/fhir/claim-decision-reason

Responsible Owner: 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-ballot3
active as of 2025-04-01 2025-11-14 Computable Name : ClaimAdjudicationDecisionReasonCodes
Flags : CaseSensitive, Complete OID : 2.16.840.1.113883.4.642.4.2130

"This This Code system is used in the following FHIR core-defined or referenced value sets:

4.3.2.219.1 4.3.2.206.1 Definition

This value set provides example Claim Adjudication Decision Reason codes.

4.3.2.219.2 4.3.2.206.2 Content

Generated Narrative: CodeSystem claim-decision-reason

Last updated: 2025-04-01T12:16:37.966+11:00 Profile: Shareable CodeSystem 2025-11-14T05:50:06.469Z

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

 

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