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 - XML Representation

Draft as of 2025-11-25

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    <CodeSystem xmlns="http://hl7.org/fhir">
      <id value="claim-decision-reason-cs"/>
      <text>
        <status value="generated"/>
        <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>
      </text>
      <url
           value="https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs"/>
      <version value="0.4.3"/>
      <name value="ClaimDecisionReasonCS"/>
      <title value="Claim Decision Reason Code System"/>
      <status value="draft"/>
      <date value="2025-11-25T02:00:55+00:00"/>
      <publisher value="Te Whatu Ora"/>
      <contact>
        <name value="Te Whatu Ora"/>
        <telecom>
          <system value="url"/>
          <value value="https://www.tewhatuora.govt.nz/"/>
        </telecom>
      </contact>
      <contact>
        <name value="Te Whatu Ora Integration Team"/>
        <telecom>
          <system value="email"/>
          <value value="integration@tewhatuora.govt.nz"/>
          <use value="work"/>
        </telecom>
      </contact>
      <description
                   value="Code system for claim decision reasons based on FHIR R5 claim-decision-reason"/>
      <jurisdiction>
        <coding>
          <system value="urn:iso:std:iso:3166"/>
          <code value="NZ"/>
          <display value="New Zealand"/>
        </coding>
      </jurisdiction>
      <caseSensitive value="true"/>
      <content value="complete"/>
      <count value="5"/>
      <concept>
        <code value="0001"/>
        <display value="Not medically necessary"/>
        <definition
                    value="The payer has determined this product, service, or procedure as not medically necessary."/>
      </concept>
      <concept>
        <code value="0002"/>
        <display value="Prior authorization not obtained"/>
        <definition
                    value="Prior authorization was not obtained prior to providing the product, service, or procedure."/>
      </concept>
      <concept>
        <code value="0003"/>
        <display value="Provider out-of-network"/>
        <definition
                    value="This provider is considered out-of-network by the payer for this plan."/>
      </concept>
      <concept>
        <code value="0004"/>
        <display value="Service inconsistent with patient age"/>
        <definition
                    value="The payer has determined this product, service, or procedure is not consistent with the patient's age."/>
      </concept>
      <concept>
        <code value="0005"/>
        <display value="Benefit limits exceeded"/>
        <definition
                    value="The patient or subscriber benefit's have been exceeded."/>
      </concept>
    </CodeSystem>