ClaimAdjudicationDecisionReasonCodes

Claim Adjudication Decision Reason Codes

activeExtensions for Using Data Elements from FHIR R5 in FHIR R40.1.0complete5 concepts

This value set provides example Claim Adjudication Decision Reason codes.

Metadata

Code	Display	Definition
`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 age.
`0005`	Benefit limits exceeded	The patient or subscriber benefit's have been exceeded.