http://hl7.org/fhir/claim-decision-reason|5.0.0

{
  "description" : "This value set provides example Claim Adjudication Decision Reason codes.",
  "compose" : null,
  "package" : "hl7.fhir.r5.core@5.0.0",
  "date" : null,
  "meta" : {
    "profile" : [ "http://hl7.org/fhir/StructureDefinition/shareablecodesystem" ],
    "lastUpdated" : "2023-03-26T15:21:02.749+11:00"
  },
  "publisher" : "HL7 International",
  "jurisdiction" : [ {
    "coding" : [ {
      "code" : "001",
      "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "display" : "World"
    } ]
  } ],
  "content" : "complete",
  "name" : "ClaimAdjudicationDecisionReasonCodes",
  "copyright" : "HL7 Inc.",
  "experimental" : false,
  "resourceType" : "CodeSystem",
  "title" : "Claim Adjudication Decision Reason Codes",
  "supliment" : null,
  "extension" : [ {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "fm"
  } ],
  "status" : "active",
  "id" : "bbf63bc6-f58c-50b6-909b-aba7420b0756",
  "url" : "http://hl7.org/fhir/claim-decision-reason",
  "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."
  } ],
  "caseSensitive" : true,
  "version" : "5.0.0"
}