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

## ValueSet: Claim Decision Reason Codes

Official URL: https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-decision-reason-codes | Version: 0.4.3
Draft as of 2025-11-25 | Computable Name: ClaimDecisionReasonCodes

Codes for claim decision reasons

References

- Shared Care Review Outcome

### Logical Definition (CLD)

- Include all codes defined in `https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs`

### Expansion

Expansion performed internally based on codesystem Claim Decision Reason Code System v0.4.3 (CodeSystem)

This value set contains 5 concepts

Code | System | Display | Definition
0001 | https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs | Not medically necessary | The payer has determined this product, service, or procedure as not medically necessary.
0002 | https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs | Prior authorization not obtained | Prior authorization was not obtained prior to providing the product, service, or procedure.
0003 | https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs | Provider out-of-network | This provider is considered out-of-network by the payer for this plan.
0004 | https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs | Service inconsistent with patient age | The payer has determined this product, service, or procedure is not consistent with the patient's age.
0005 | https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs | Benefit limits exceeded | The patient or subscriber benefit's have been exceeded.

Explanation of the columns that may appear on this page:

Level | A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System | The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code | The code (used as the code in the resource instance)
Display | The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition | An explanation of the meaning of the concept
Comments | Additional notes about how to use the code