Health Care Services Decision Reason Codes

$179 / year

Health Care Services Decision Reason Codes are used to indicate the primary reason for the certification action code assigned as part of a health care services review for all medical claims. This dataset also contains information on the different decision reason codes and their descriptions, the start and modified dates, and the status for each code.


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) carries provisions for administrative simplification. This requires the Secretary of the federal Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans.
The objective of this standardization such as the Health Care Services Decision Reason Codes is to create better access to health insurance, limit fraud and abuse and reduce administrative costs in terms of health care services review.

The Centers for Medicare & Medicaid Services (CMS) maintain and annually update a List of Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) Codes (Code List), which identifies all the items and services included within certain DHS categories. CMS updates the Code List to conform the list to the most recent publications of CPT and HCPCS and to account for changes in Medicare coverage and payment policies. The updated Code List is published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. That rule is usually published in November and generally becomes effective January 1 of the following year. In addition, we may publish other rules or correction notices that may change the Code List. CMS posts any changes to the Code List on its webpage as soon as possible after publication in the Federal Register.

The DHS categories defined by the Code List are:
– Clinical laboratory services;
– Physical therapy services, occupational therapy services, outpatient speech-language pathology services;
– Radiology and certain other imaging services; and
– Radiation therapy services and supplies.

**NOTE**: The following DHS categories are defined at 42 CFR ยง411.351 without reference to the Code List:
– Durable medical equipment and supplies;
– Parenteral and enteral nutrients, equipment and supplies;
– Prosthetics, orthotics, and prosthetic devices and supplies;
– Home health services;
– Outpatient prescription drugs; and
– Inpatient and outpatient hospital services.

Date Created


Last Modified




Update Frequency


Temporal Coverage

2001 to 2017

Spatial Coverage

United States


John Snow Labs; Centers of Medicare and Medicaid Services (CMS);

Source License URL

Source License Requirements


Source Citation



Health Care Services Decision Reason Codes, ASC X12 External Code Source 886, Health Care Services Review, Certification Codes, Health Costs, Health Insurance, Medicare Denial Codes, Denial Codes in Medical Billing, Medicare Reason Codes

Other Titles

Health Insurance Portability and Accountability Act (HIPAA) Standard Electronic Transactions, Medicare Appropriate Health Care Services Decision Reason Codes, Health Care Services Decision Reason Codes for Specific Health Care Services review, Health Care Services Certification, Health Costs and Health Care Services Decision Reason Codes, Insurance and Health Care Services Decision Reason Codes, Rising Healthcare and Health Care Services Decision Reason Codes

CodeHealth Care Services Decision Reason Codesstringrequired : 1 unique : 1
DescriptionDescription for each Health Care Services Decision Reason Codestringrequired : 1 unique : 1
Start_DateDate the Health Care Services Decision Reason Code started usagedaterequired : 1
Last_ModifiedDate the Health Care Services Type Code was changed/modifieddate-
StatusCode update whether Active, To be Deactivated or Deactivatedstringrequired : 1
NotesExplanation of Health Care Services Decision Reason Code uses and redundant and/or replacement codesstring-
CodeDescriptionStart DateLast ModifiedStatusNotes
1Price Authorization Expired2001-01-10Active
2Price authorization no longer required2001-01-10Active
3Product not on the price authorization2001-01-10Active
4Authorized Quantity Exceeded2001-01-10Active
5Special Cost Incorrect2001-01-10Active
6No Credit Allowed2001-01-10Active
7Administrative Cancellation2001-01-10Active
8Unit Resale higher than authorized2001-01-10Active
9Out of Network2001-01-10Active
0ATesting not Included2001-01-10Active