<?xml version="1.0" encoding="UTF-8"?><CodeSystem xmlns="http://hl7.org/fhir"><id value="claim-decision-reason"/><meta><lastUpdated value="2026-03-31T17:43:31.836+00:00"/></meta><text><status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem claim-decision-reason</b></p><a name="claim-decision-reason"> </a><a name="hcclaim-decision-reason"> </a><p>This case-sensitive code system <code>http://hl7.org/fhir/claim-decision-reason</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">0001<a name="claim-decision-reason-0001"> </a></td><td>Not medically necessary</td><td>The payer has determined this product, service, or procedure as not medically necessary.</td></tr><tr><td style="white-space:nowrap">0002<a name="claim-decision-reason-0002"> </a></td><td>Prior authorization not obtained</td><td>Prior authorization was not obtained prior to providing the product, service, or procedure.</td></tr><tr><td style="white-space:nowrap">0003<a name="claim-decision-reason-0003"> </a></td><td>Provider out-of-network</td><td>This provider is considered out-of-network by the payer for this plan.</td></tr><tr><td style="white-space:nowrap">0004<a name="claim-decision-reason-0004"> </a></td><td>Service inconsistent with patient age</td><td>The payer has determined this product, service, or procedure is not consistent with the patient's age.</td></tr><tr><td style="white-space:nowrap">0005<a name="claim-decision-reason-0005"> </a></td><td>Benefit limits exceeded</td><td>The patient or subscriber benefit's have been exceeded.</td></tr></table></div></text><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-ballot4"/><name value="ClaimAdjudicationDecisionReasonCodes"/><title value="Claim Adjudication Decision Reason Codes"/><status value="active"/><experimental value="false"/><publisher value="HL7 International"/><description value="This value set provides example Claim Adjudication Decision Reason codes."/><jurisdiction><coding><system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/><code value="001"/><display value="World"/></coding></jurisdiction><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>