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