http://hl7.org/fhir/claim-decision-reason|5.0.0
name
ClaimAdjudicationDecisionReasonCodes
ClaimAdjudicationDecisionReasonCodes
package
hl7.fhir.r5.core@5.0.0
hl7.fhir.r5.core@5.0.0
content
complete
complete
status
active
active
Claim Adjudication Decision Reason Codes
This value set provides example Claim Adjudication Decision Reason codes.
| code | display | definition | hierarchy |
|---|---|---|---|
| 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 ag... | |
| 0005 | Benefit limits exceeded | The patient or subscriber benefit's have been exceeded.... |