Definition for Code SystemClaimAdjudicationDecisionReasonCodes

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      This code system 
         defines the following codes:
      
      
        
          
            
          
          
            
          
          
            
          
        
        
          0001
            
          
          
          
        
        
          0002
            
          
          

<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="claim-decision-reason"/> 
  <meta> 
    <lastUpdated value="2025-11-14T05:50:06.469+00:00"/> 
  </meta> 
  <text> 
    <status value="generated"/> 
    <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.
        
        
          0003
            
          
          
          
        
        
          0004
            
          
          

             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.
        
        
          0005
            
          
          
          
        
      
    
  
  
    
  
  
  
  
  
  
  
  
  
  
    
      
      
      
    
  
  
  
  
  
    
    
    
  
  
    
    

             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>   </text>   <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">    <valueCode value="fm"/>   </extension>   <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">    <valueCode value="informative"/>   </extension>   <url value="http://hl7.org/fhir/claim-decision-reason"/>   <identifier>     <system value="urn:ietf:rfc:3986"/>     <value value="urn:oid:2.16.840.1.113883.4.642.4.2130"/>   </identifier>   <version value="6.0.0-ballot3"/>   <name value="ClaimAdjudicationDecisionReasonCodes"/>   <title value="Claim Adjudication Decision Reason Codes"/>   <status value="active"/>   <experimental value="false"/>   <publisher value="HL7 International"/>   <description value="This value set provides example Claim Adjudication Decision Reason codes."/>   <jurisdiction>     <coding>       <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>       <code value="001"/>       <display value="World"/>     </coding>   </jurisdiction>   <copyright value="HL7 Inc."/>   <caseSensitive value="true"/>   <content value="complete"/>   <concept>     <code value="0001"/>     <display value="Not medically necessary"/>     <definition value="The payer has determined this product, service, or procedure as not medically necessary."/>   </concept>   <concept>     <code value="0002"/>     <display value="Prior authorization not obtained"/> 
    <definition value="Prior authorization was not obtained prior to providing the product, service, or
     procedure.
  
  
    
    
    
  
  
    
    

     procedure."/> 
  </concept>   <concept>     <code value="0003"/>     <display value="Provider out-of-network"/>     <definition value="This provider is considered out-of-network by the payer for this plan."/>   </concept>   <concept>     <code value="0004"/>     <display value="Service inconsistent with patient age"/> 
    <definition value="The payer has determined this product, service, or procedure is not consistent
     with the patient's age.
  
  
    
    
    
  

     with the patient's age."/> 
  </concept>   <concept>     <code value="0005"/>     <display value="Benefit limits exceeded"/>     <definition value="The patient or subscriber benefit's have been exceeded."/>   </concept> 


</

CodeSystem

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