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TX: CodeSystem claim-decision-reason

Properties

Profile http://hl7.org/fhir/StructureDefinition/shareablecodesystem
Last updated: March 26, 2023 at 04:21:02 AM UTC
Defining URL http://hl7.org/fhir/claim-decision-reason
Version 5.0.0
Name ClaimAdjudicationDecisionReasonCodes
Title Claim Adjudication Decision Reason Codes
Status active
Definition

This value set provides example Claim Adjudication Decision Reason codes.
Publisher HL7 International
Committee fm
Copyright HL7 Inc.
Source hl7.fhir.r5.core#5.0.0

This case-sensitive code system http://hl7.org/fhir/claim-decision-reason defines the following codes:

Code Display Definition
0001 Not medically necessary The payer has determined this product, service, or procedure as not medically necessary.
0002 Prior authorization not obtained Prior authorization was not obtained prior to providing the product, service, or procedure.
0003 Provider out-of-network This provider is considered out-of-network by the payer for this plan.
0004 Service inconsistent with patient age The payer has determined this product, service, or procedure is not consistent with the patient's age.
0005 Benefit limits exceeded The patient or subscriber benefit's have been exceeded.