Health New Zealand Te Whatu Ora Shared Care FHIR API
0.4.3 - release

Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.3) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## : Claim Decision Reason Code System - JSON Representation

Draft as of 2025-11-25

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    {
      "resourceType" : "CodeSystem",
      "id" : "claim-decision-reason-cs",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem claim-decision-reason-cs</b></p><a name=\"claim-decision-reason-cs\"> </a><a name=\"hcclaim-decision-reason-cs\"> </a><p>This case-sensitive code system <code>https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">0001<a name=\"claim-decision-reason-cs-0001\"> </a></td><td>Not medically necessary</td><td>The payer has determined this product, service, or procedure as not medically necessary.</td></tr><tr><td style=\"white-space:nowrap\">0002<a name=\"claim-decision-reason-cs-0002\"> </a></td><td>Prior authorization not obtained</td><td>Prior authorization was not obtained prior to providing the product, service, or procedure.</td></tr><tr><td style=\"white-space:nowrap\">0003<a name=\"claim-decision-reason-cs-0003\"> </a></td><td>Provider out-of-network</td><td>This provider is considered out-of-network by the payer for this plan.</td></tr><tr><td style=\"white-space:nowrap\">0004<a name=\"claim-decision-reason-cs-0004\"> </a></td><td>Service inconsistent with patient age</td><td>The payer has determined this product, service, or procedure is not consistent with the patient's age.</td></tr><tr><td style=\"white-space:nowrap\">0005<a name=\"claim-decision-reason-cs-0005\"> </a></td><td>Benefit limits exceeded</td><td>The patient or subscriber benefit's have been exceeded.</td></tr></table></div>"
      },
      "url" : "https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs",
      "version" : "0.4.3",
      "name" : "ClaimDecisionReasonCS",
      "title" : "Claim Decision Reason Code System",
      "status" : "draft",
      "date" : "2025-11-25T02:00:55+00:00",
      "publisher" : "Te Whatu Ora",
      "contact" : [
        {
          "name" : "Te Whatu Ora",
          "telecom" : [
            {
              "system" : "url",
              "value" : "https://www.tewhatuora.govt.nz/"
            }
          ]
        },
        {
          "name" : "Te Whatu Ora Integration Team",
          "telecom" : [
            {
              "system" : "email",
              "value" : "integration@tewhatuora.govt.nz",
              "use" : "work"
            }
          ]
        }
      ],
      "description" : "Code system for claim decision reasons based on FHIR R5 claim-decision-reason",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "urn:iso:std:iso:3166",
              "code" : "NZ",
              "display" : "New Zealand"
            }
          ]
        }
      ],
      "caseSensitive" : true,
      "content" : "complete",
      "count" : 5,
      "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."
        }
      ]
    }