{
  "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" : "0.4.4",
  "name" : "ClaimDecisionReasonCS",
  "title" : "Claim Decision Reason Code System",
  "status" : "draft",
  "date" : "2025-12-11T23:52:07+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."
  }]
}