{"caseSensitive":true,"concept":[{"code":"0001","definition":"The payer has determined this product, service, or procedure as not medically necessary.","display":"Not medically necessary"},{"code":"0002","definition":"Prior authorization was not obtained prior to providing the product, service, or procedure.","display":"Prior authorization not obtained"},{"code":"0003","definition":"This provider is considered out-of-network by the payer for this plan.","display":"Provider out-of-network"},{"code":"0004","definition":"The payer has determined this product, service, or procedure is not consistent with the patient's age.","display":"Service inconsistent with patient age"},{"code":"0005","definition":"The patient or subscriber benefit's have been exceeded.","display":"Benefit limits exceeded"}],"content":"complete","copyright":"HL7 Inc.","description":"This value set provides example Claim Adjudication Decision Reason codes.","experimental":false,"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/structuredefinition-wg","valueCode":"fm"},{"url":"http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status","valueCode":"informative"}],"id":"claim-decision-reason","identifier":[{"system":"urn:ietf:rfc:3986","value":"urn:oid:2.16.840.1.113883.4.642.4.2130"}],"jurisdiction":[{"coding":[{"code":"001","display":"World","system":"http://unstats.un.org/unsd/methods/m49/m49.htm"}]}],"meta":{"lastUpdated":"2026-04-03T20:06:10.198+00:00"},"name":"ClaimAdjudicationDecisionReasonCodes","publisher":"HL7 International","resourceType":"CodeSystem","status":"active","text":{"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><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>","status":"generated"},"title":"Claim Adjudication Decision Reason Codes","url":"http://hl7.org/fhir/claim-decision-reason","version":"6.0.0-ballot4"}