Definition for Code SystemClaimAdjudicationDecisionReasonCodes

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

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<http://hl7.org/fhir/CodeSystem/claim-decision-reason> a fhir:CodeSystem ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "claim-decision-reason"] ; # 
  fhir:meta [
     fhir:lastUpdated [ fhir:v "2025-10-20T19:36:06.320+00:00"^^xsd:dateTime ] ;
     fhir:profile ( [
       fhir:v "http://hl7.org/fhir/StructureDefinition/shareablecodesystem"^^xsd:anyURI ;
       fhir:link <http://hl7.org/fhir/StructureDefinition/shareablecodesystem>
     ] )
  ] ; # 
  fhir:text [
     fhir:status [ fhir:v "generated" ] ;
     fhir:div "<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><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"shareablecodesystem.html\">Shareable CodeSystem</a></p></div><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>"^^rdf:XMLLiteral
  ] ; # 
  fhir:extension ( [
     fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ;
     fhir:value [
       a fhir:code ;
       fhir:v "fm"
     ]
  ] ) ; # 
  fhir:url [ fhir:v "http://hl7.org/fhir/claim-decision-reason"^^xsd:anyURI] ; # 
  fhir:identifier ( [
     fhir:system [ fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ] ;
     fhir:value [ fhir:v "urn:oid:2.16.840.1.113883.4.642.4.2130" ]
  ] ) ; # 
  fhir:version [ fhir:v "6.0.0-ballot3"] ; # 
  fhir:name [ fhir:v "ClaimAdjudicationDecisionReasonCodes"] ; # 
  fhir:title [ fhir:v "Claim Adjudication Decision Reason Codes"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:experimental [ fhir:v false] ; # 
  fhir:publisher [ fhir:v "HL7 International"] ; # 
  fhir:description [ fhir:v "This value set provides example Claim Adjudication Decision Reason codes."] ; # 
  fhir:jurisdiction ( [
     fhir:coding ( [
       fhir:system [ fhir:v "http://unstats.un.org/unsd/methods/m49/m49.htm"^^xsd:anyURI ] ;
       fhir:code [ fhir:v "001" ] ;
       fhir:display [ fhir:v "World" ]
     ] )
  ] ) ; # 
  fhir:copyright [ fhir:v "HL7 Inc."] ; # 
  fhir:caseSensitive [ fhir:v true] ; # 
  fhir:hierarchyMeaning [] ; # 
  fhir:content [ fhir:v "complete"] ; # 
  fhir:concept ( [
     fhir:code [ fhir:v "0001" ] ;
     fhir:display [ fhir:v "Not medically necessary" ] ;
     fhir:definition [ fhir:v "The payer has determined this product, service, or procedure as not medically necessary." ]
  ] [
     fhir:code [ fhir:v "0002" ] ;
     fhir:display [ fhir:v "Prior authorization not obtained" ] ;
     fhir:definition [ fhir:v "Prior authorization was not obtained prior to providing the product, service, or procedure." ]
  ] [
     fhir:code [ fhir:v "0003" ] ;
     fhir:display [ fhir:v "Provider out-of-network" ] ;
     fhir:definition [ fhir:v "This provider is considered out-of-network by the payer for this plan." ]
  ] [
     fhir:code [ fhir:v "0004" ] ;
     fhir:display [ fhir:v "Service inconsistent with patient age" ] ;
     fhir:definition [ fhir:v "The payer has determined this product, service, or procedure is not consistent with the patient's age." ]
  ] [
     fhir:code [ fhir:v "0005" ] ;
     fhir:display [ fhir:v "Benefit limits exceeded" ] ;
     fhir:definition [ fhir:v "The patient or subscriber benefit's have been exceeded." ]
  ] ) . # 

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