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

4.4.1.321 4.4.1.338 ValueSet http://hl7.org/fhir/ValueSet/claim-decision-reason

Financial Management icon Work Group   Maturity Level : 1 Draft Use Context : Country: World, Not Intended for Production use World
Official URL : http://hl7.org/fhir/ValueSet/claim-decision-reason Version : 5.0.0 6.0.0-ballot3
draft as of 2023-03-26 2025-04-01 Computable Name : ClaimAdjudicationDecisionReasonCodes
Flags : Experimental OID : 2.16.840.1.113883.4.642.3.3338

This value set is used in the following places:

4.4.1.321.1 4.4.1.338.1 Definition

This value set includes example Claim Adjudication Decision Reason codes.

4.4.1.321.2 4.4.1.338.2 Content Logical Definition

Generated Narrative: ValueSet claim-decision-reason

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

Profile: Shareable ValueSet

 

4.4.1.321.3 4.4.1.338.3 Expansion

This expansion generated 26 Mar 2023 01 Apr 2025

This value set contains 5 concepts

ValueSet

Expansion performed internally based on codesystem Claim Adjudication Decision Reason Codes v5.0.0 v6.0.0-ballot3 (CodeSystem)

This value set contains 5 concepts

Code System Display Definition
   0001 http://hl7.org/fhir/claim-decision-reason Not medically necessary

The payer has determined this product, service, or procedure as not medically necessary.

   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.

   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.

   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.

   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