---
type: "codesystem"
title: "Claim Adjudication Decision Reason Codes"
codesystem: "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
<?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>
```