{
  "description": "This value set provides example Claim Adjudication Decision Reason codes.",
  "_filename": "CodeSystem-claim-decision-reason.json",
  "package_name": "hl7.fhir.uv.xver-r5.r4",
  "date": "2025-09-13T16:55:28-04:00",
  "publisher": "Financial Management",
  "jurisdiction": [ {
    "coding": [ {
      "code": "001",
      "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "display": "World"
    } ]
  } ],
  "content": "complete",
  "name": "ClaimAdjudicationDecisionReasonCodes",
  "copyright": "HL7 Inc.",
  "type": null,
  "experimental": "false",
  "resourceType": "CodeSystem",
  "title": "Claim Adjudication Decision Reason Codes",
  "package_version": "0.0.1-snapshot-2",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/package-source",
    "extension": [ {
      "url": "packageId",
      "valueId": "hl7.fhir.uv.xver-r5.r4"
    }, {
      "url": "version",
      "valueString": "0.0.1-snapshot-2"
    } ]
  }, {
    "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode": "fm"
  } ],
  "status": "active",
  "id": "4781a6b9-8b69-4a8e-b5dc-271d0f21a77a",
  "kind": null,
  "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",
  "contact": [ {
    "name": "Financial Management",
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/fm",
      "system": "url"
    } ]
  } ]
}