Definition for Code SystemClaimAdjudicationDecisionReasonCodes

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

<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="claim-decision-reason"/> 
  <meta> 
    <lastUpdated value="2024-11-19T23:55:04.453+00:00"/> 
    <profile value="http://hl7.org/fhir/StructureDefinition/shareablecodesystem"/> 
  </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> 
      <a name="claim-decision-reason-en-US"> </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> 
  <url value="http://hl7.org/fhir/claim-decision-reason"/> 
  <version value="6.0.0-ballot2"/> 
  <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>