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 - TTL Representation

Draft as of 2025-11-25

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:CodeSystem ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "claim-decision-reason-cs"] ; #
      fhir:text [
    fhir:status [ fhir:v "generated" ] ;
    fhir: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>"^^rdf:XMLLiteral
      ] ; #
      fhir:url [ fhir:v "https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs"^^xsd:anyURI] ; #
      fhir:version [ fhir:v "0.4.3"] ; #
      fhir:name [ fhir:v "ClaimDecisionReasonCS"] ; #
      fhir:title [ fhir:v "Claim Decision Reason Code System"] ; #
      fhir:status [ fhir:v "draft"] ; #
      fhir:date [ fhir:v "2025-11-25T02:00:55+00:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "Te Whatu Ora"] ; #
      fhir:contact ( [
    fhir:name [ fhir:v "Te Whatu Ora" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "https://www.tewhatuora.govt.nz/" ]     ] )
      ] [
    fhir:name [ fhir:v "Te Whatu Ora Integration Team" ] ;
        ( fhir:telecom [
    fhir:system [ fhir:v "email" ] ;
    fhir:value [ fhir:v "integration@tewhatuora.govt.nz" ] ;
    fhir:use [ fhir:v "work" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "Code system for claim decision reasons based on FHIR R5 claim-decision-reason"] ; #
      fhir:jurisdiction ( [
        ( fhir:coding [
    fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "NZ" ] ;
    fhir:display [ fhir:v "New Zealand" ]     ] )
      ] ) ; #
      fhir:caseSensitive [ fhir:v true] ; #
      fhir:content [ fhir:v "complete"] ; #
      fhir:count [ fhir:v "5"^^xsd:nonNegativeInteger] ; #
      fhir:concept ( [
    fhir:code [ fhir:v "0001" ] ;
    fhir:display [ fhir:v "Not medically necessary" ] ;
    fhir:definition [ fhir:v "The payer has determined this product, service, or procedure as not medically necessary." ]
      ] [
    fhir:code [ fhir:v "0002" ] ;
    fhir:display [ fhir:v "Prior authorization not obtained" ] ;
    fhir:definition [ fhir:v "Prior authorization was not obtained prior to providing the product, service, or procedure." ]
      ] [
    fhir:code [ fhir:v "0003" ] ;
    fhir:display [ fhir:v "Provider out-of-network" ] ;
    fhir:definition [ fhir:v "This provider is considered out-of-network by the payer for this plan." ]
      ] [
    fhir:code [ fhir:v "0004" ] ;
    fhir:display [ fhir:v "Service inconsistent with patient age" ] ;
    fhir:definition [ fhir:v "The payer has determined this product, service, or procedure is not consistent with the patient's age." ]
      ] [
    fhir:code [ fhir:v "0005" ] ;
    fhir:display [ fhir:v "Benefit limits exceeded" ] ;
    fhir:definition [ fhir:v "The patient or subscriber benefit's have been exceeded." ]
      ] ) . #