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Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative |
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Definition for Code SystemClaimAdjudicationDecisionReasonCodes
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- [a fhir:CodeSystem ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "claim-decision-reason"] ; # fhir:meta [ fhir:lastUpdated [ fhir:v "2025-02-08T05:46:53.041+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><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>" ] ; # fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ; fhir:value [ fhir:v "fm" ] ] ) ; # fhir:url [ fhir:v "http://hl7.org/fhir/claim-decision-reason"^^xsd:anyURI] ; # fhir:version [ fhir:v "6.0.0-ballot2"] ; # fhir:name [ fhir:v "ClaimAdjudicationDecisionReasonCodes"] ; # fhir:title [ fhir:v "Claim Adjudication Decision Reason Codes"] ; # fhir:status [ fhir:v "active"] ; # fhir:experimental [ fhir:v "false"^^xsd:boolean] ; # 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"^^xsd:boolean] ; # 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." ] ] )] . # # -------------------------------------------------------------------------------------
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Sat, Feb 8, 2025 06:24+0000.
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