This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon ValueSet http://hl7.org/fhir/ValueSet/claim-decision-reason

Financial Management icon Work Group Maturity Level: 0Informative Use Context: Country: World
Official URL: http://hl7.org/fhir/ValueSet/claim-decision-reason Version: 6.0.0-cibuild
draft as of 2024-06-17 Computable Name: ClaimAdjudicationDecisionReasonCodes
Flags: OID:

This value set is used in the following places:

This value set includes example Claim Adjudication Decision Reason codes.


This expansion generated 17 Jun 2024

Expansion based on codesystem Claim Adjudication Decision Reason Codes v6.0.0-cibuild (CodeSystem)

This value set contains 5 concepts.

  0001http://hl7.org/fhir/claim-decision-reasonNot medically necessary

The payer has determined this product, service, or procedure as not medically necessary.

  0002http://hl7.org/fhir/claim-decision-reasonPrior authorization not obtained

Prior authorization was not obtained prior to providing the product, service, or procedure.

  0003http://hl7.org/fhir/claim-decision-reasonProvider out-of-network

This provider is considered out-of-network by the payer for this plan.

  0004http://hl7.org/fhir/claim-decision-reasonService inconsistent with patient age

The payer has determined this product, service, or procedure is not consistent with the patient's age.

  0005http://hl7.org/fhir/claim-decision-reasonBenefit limits exceeded

The patient or subscriber benefit's have been exceeded.


See the full registry of value sets defined as part of FHIR.

Explanation of the columns that may appear on this page:

LvlA few code lists that FHIR defines are hierarchical - each code is assigned a level. For value sets, levels are mostly used to organize codes for user convenience, but may follow code system hierarchy - see Code System for further information
SourceThe source of the definition of the code (when the value set draws in codes defined elsewhere)
CodeThe code (used as the code in the resource instance). If the code is in italics, this indicates that the code is not selectable ('Abstract')
DisplayThe display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
DefinitionAn explanation of the meaning of the concept
CommentsAdditional notes about how to use the code