<?xml version="1.0" encoding="UTF-8"?>

<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="0.4.4"/>
  <name value="ClaimDecisionReasonCS"/>
  <title value="Claim Decision Reason Code System"/>
  <status value="draft"/>
  <date value="2025-12-11T23:52:07+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>