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

## CodeSystem: Claim Decision Reason Code System

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

Code system for claim decision reasons based on FHIR R5 claim-decision-reason

This Code system is referenced in the content logical definition of the following value sets:

- ClaimDecisionReasonCodes

This case-sensitive code system `https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs` defines the following codes:

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.