type: codesystemcodesystem: claim-decision-reason

Claim Adjudication Decision Reason Codes

Official URL: http://hl7.org/fhir/claim-decision-reason
Version: 6.0.0
Status: active
Name: ClaimAdjudicationDecisionReasonCodes
Title: Claim Adjudication Decision Reason Codes
Description: This value set provides example Claim Adjudication Decision Reason codes.
Case Sensitive: true
Content: complete

Concepts

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

CodeSystem XML

<?xml version="1.0" encoding="UTF-8"?>

<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="claim-decision-reason"/>
  <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"/>
  <name value="ClaimAdjudicationDecisionReasonCodes"/>
  <title value="Claim Adjudication Decision Reason Codes"/>
  <status value="active"/>
  <experimental value="false"/>
  <description value="This value set provides example Claim Adjudication Decision Reason codes."/>
  <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."/>
  </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."/>
  </concept>
  <concept>
    <code value="0005"/>
    <display value="Benefit limits exceeded"/>
    <definition value="The patient or subscriber benefit's have been exceeded."/>
  </concept>
</CodeSystem>