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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4.4.1.338 4.4.1.608 ValueSet http://hl7.org/fhir/ValueSet/claim-decision-reason

Responsible Owner: Financial Management icon Work Group   Maturity Level : 1 Draft Use Context : Country: World
Official URL : http://hl7.org/fhir/ValueSet/claim-decision-reason Version : 6.0.0-ballot3
draft as of 2025-04-01 2025-11-10 Computable Name : ClaimAdjudicationDecisionReasonCodes
Flags : OID : 2.16.840.1.113883.4.642.3.3338

This value set is used in the following places:

4.4.1.338.1 4.4.1.608.1 Definition

This value set includes example Claim Adjudication Decision Reason codes.

4.4.1.338.2 4.4.1.608.2 Content Logical Definition

Generated Narrative: ValueSet claim-decision-reason

Last updated: 2025-04-01T12:16:37.966+11:00 Profile: Shareable ValueSet 2025-11-10T15:17:08.817Z

 

4.4.1.338.3 4.4.1.608.3 Expansion

This expansion generated 01 Apr 10 Nov 2025

ValueSet

Expansion performed internally based on codesystem Claim Adjudication Decision Reason Codes v6.0.0-ballot3 (CodeSystem)

This value set contains 5 concepts

Code System System Code Display Definition
http://hl7.org/fhir/claim-decision-reason    0001 http://hl7.org/fhir/claim-decision-reason Not medically necessary The payer has determined this product, service, or procedure as not medically necessary.
http://hl7.org/fhir/claim-decision-reason    0002 http://hl7.org/fhir/claim-decision-reason Prior authorization not obtained Prior authorization was not obtained prior to providing the product, service, or procedure.
http://hl7.org/fhir/claim-decision-reason    0003 http://hl7.org/fhir/claim-decision-reason Provider out-of-network This provider is considered out-of-network by the payer for this plan.
http://hl7.org/fhir/claim-decision-reason    0004 http://hl7.org/fhir/claim-decision-reason Service inconsistent with patient age The payer has determined this product, service, or procedure is not consistent with the patient's age.
http://hl7.org/fhir/claim-decision-reason    0005 http://hl7.org/fhir/claim-decision-reason Benefit limits exceeded The patient or subscriber benefit's have been exceeded.

 

See the full registry of value sets defined as part of FHIR.

Explanation of the columns that may appear on this page:

Lvl A few code lists that FHIR defines are hierarchical - each code is assigned a level. For value sets, levels are mostly used to organize codes for user convenience, but may follow code system hierarchy - 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