{
  "description": "This value set provides example Claim Adjudication Decision Reason codes.",
  "_filename": "CodeSystem-claim-decision-reason.json",
  "package_name": "hl7.fhir.r6.examples",
  "date": null,
  "meta": {
    "profile": [ "http://hl7.org/fhir/StructureDefinition/shareablecodesystem" ],
    "lastUpdated": "2024-08-12T16:52:12.437+08:00"
  },
  "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.",
  "type": null,
  "experimental": "false",
  "resourceType": "CodeSystem",
  "title": "Claim Adjudication Decision Reason Codes",
  "package_version": "6.0.0-ballot2",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode": "fm"
  } ],
  "status": "active",
  "id": "ff900842-706b-416e-a004-a7be80f91a0e",
  "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": "6.0.0-ballot2"
}