Definition for Code SystemClaimAdjudicationDecisionReasonCodes

{
  "resourceType" : "CodeSystem",
  "id" : "claim-decision-reason",
  "meta" : {
    "lastUpdated" : "2023-03-26T15:21:02.749+11:00",
    "profile" : ["http://hl7.org/fhir/StructureDefinition/shareablecodesystem"]

    "lastUpdated" : "2025-11-20T23:56:49.898+00:00"

  },
  "text" : {
    "status" : "generated",
    "div" : "<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>"

    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem claim-decision-reason</b></p><a name=\"claim-decision-reason\"> </a><a name=\"hcclaim-decision-reason\"> </a><p>This case-sensitive 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>"

  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "fm"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "informative"

  }],
  "url" : "http://hl7.org/fhir/claim-decision-reason",
  "version" : "5.0.0",

  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.4.2130"
  }],
  "version" : "6.0.0-ballot3",

  "name" : "ClaimAdjudicationDecisionReasonCodes",
  "title" : "Claim Adjudication Decision Reason Codes",
  "status" : "active",
  "experimental" : false,
  "publisher" : "HL7 International",
  "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."
  }]
}