Release 5 R6 Ballot (3rd Draft)

This page is part of the FHIR Specification (v5.0.0: R5 - STU v6.0.0-ballot3: Release 6 Ballot (3rd Draft) (see Ballot Notes ). This is the The current published version in it's permanent home (it will always be available at this URL). is 5.0.0 . For a full list of available versions, see the Directory of published versions

4.3.2.211 4.3.2.219 CodeSystem http://hl7.org/fhir/claim-decision-reason

Financial Management icon Work Group   Maturity Level : 0 Informative Use Context : Country: World
Official URL : http://hl7.org/fhir/claim-decision-reason Version : 5.0.0 6.0.0-ballot3
active as of 2023-03-26 2025-04-01 Computable Name : ClaimAdjudicationDecisionReasonCodes
Flags : CaseSensitive, Complete OID : TBD 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:

4.3.2.211.1 4.3.2.219.1 Definition

This value set provides example Claim Adjudication Decision Reason codes.

4.3.2.211.2 4.3.2.219.2 Content

Generated Narrative: CodeSystem claim-decision-reason

Last updated: 2025-04-01T12:16:37.966+11:00

Profile: Shareable CodeSystem

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