Claim Adjudication Decision Reason Codes

{
  "description" : "This value set provides example Claim Adjudication Decision Reason codes.",
  "meta" : {
    "lastUpdated" : "2023-03-26T15:21:02.749+11:00",
    "profile" : [ "http://hl7.org/fhir/StructureDefinition/shareablecodesystem" ]
  },
  "publisher" : "HL7 International",
  "jurisdiction" : [ {
    "coding" : [ {
      "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "code" : "001",
      "display" : "World"
    } ]
  } ],
  "content" : "complete",
  "property" : null,
  "name" : "ClaimAdjudicationDecisionReasonCodes",
  "copyright" : "HL7 Inc.",
  "experimental" : false,
  "resourceType" : "CodeSystem",
  "title" : "Claim Adjudication Decision Reason Codes",
  "extension" : [ {
    "valueCode" : "fm",
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"
  }, {
    "extension" : [ {
      "valueString" : "concept",
      "url" : "path"
    }, {
      "url" : "count",
      "valueInteger" : 5
    } ],
    "url" : "http://health-samurai.io/extensions/excised-data"
  }, {
    "url" : "http://health-samurai.io/extensions/source",
    "valueCode" : "db"
  } ],
  "status" : "active",
  "id" : "claim-decision-reason",
  "url" : "http://hl7.org/fhir/claim-decision-reason",
  "caseSensitive" : true,
  "version" : "5.0.0",
  "text" : {
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n            <p>This code system \n              <code>http://hl7.org/fhir/claim-decision-reason</code> defines the following codes:\n            </p>\n            <table class=\"codes\">\n              <tr>\n                <td style=\"white-space:nowrap\">\n                  <b>Code</b>\n                </td>\n                <td>\n                  <b>Display</b>\n                </td>\n                <td>\n                  <b>Definition</b>\n                </td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0001\n                  <a name=\"claim-decision-reason-0001\"> </a>\n                </td>\n                <td>Not medically necessary</td>\n                <td>The payer has determined this product, service, or procedure as not medically necessary.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0002\n                  <a name=\"claim-decision-reason-0002\"> </a>\n                </td>\n                <td>Prior authorization not obtained</td>\n                <td>Prior authorization was not obtained prior to providing the product, service, or procedure.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0003\n                  <a name=\"claim-decision-reason-0003\"> </a>\n                </td>\n                <td>Provider out-of-network</td>\n                <td>This provider is considered out-of-network by the payer for this plan.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0004\n                  <a name=\"claim-decision-reason-0004\"> </a>\n                </td>\n                <td>Service inconsistent with patient age</td>\n                <td>The payer has determined this product, service, or procedure is not consistent with the patient's age.</td>\n              </tr>\n              <tr>\n                <td style=\"white-space:nowrap\">0005\n                  <a name=\"claim-decision-reason-0005\"> </a>\n                </td>\n                <td>Benefit limits exceeded</td>\n                <td>The patient or subscriber benefit's have been exceeded.</td>\n              </tr>\n            </table>\n          </div>",
    "status" : "generated"
  }
}