Health New Zealand Te Whatu Ora Shared Care FHIR API
0.4.5 - release New Zealand flag

Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.5) 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 2026-03-03

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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\">DET040.014<a name=\"claim-decision-reason-cs-DET040.46014\"> </a></td><td>Passed</td><td>A valid claim date has been provided.</td></tr><tr><td style=\"white-space:nowrap\">DET040.015<a name=\"claim-decision-reason-cs-DET040.46015\"> </a></td><td>Failed</td><td>Claim date provided is not valid.</td></tr><tr><td style=\"white-space:nowrap\">DET052.001<a name=\"claim-decision-reason-cs-DET052.46001\"> </a></td><td>Passed</td><td>No duplicate found for this claim</td></tr><tr><td style=\"white-space:nowrap\">DET052.002<a name=\"claim-decision-reason-cs-DET052.46002\"> </a></td><td>Failed</td><td>Claim is a duplicate of claim [Claim Number] received on [Received Date].</td></tr><tr><td style=\"white-space:nowrap\">DET001.006<a name=\"claim-decision-reason-cs-DET001.46006\"> </a></td><td>Passed</td><td>Agreement is valid for {service name} services</td></tr><tr><td style=\"white-space:nowrap\">DET001.001<a name=\"claim-decision-reason-cs-DET001.46001\"> </a></td><td>Failed</td><td>Agreement number provided cannot be found in our records</td></tr><tr><td style=\"white-space:nowrap\">DET001.007<a name=\"claim-decision-reason-cs-DET001.46007\"> </a></td><td>Failed</td><td>Agreement is not valid for {service name} services</td></tr><tr><td style=\"white-space:nowrap\">DET063.003<a name=\"claim-decision-reason-cs-DET063.46003\"> </a></td><td>Passed</td><td>Provider HPI organisation is appropriate for the Agreement</td></tr><tr><td style=\"white-space:nowrap\">DET063.004<a name=\"claim-decision-reason-cs-DET063.46004\"> </a></td><td>Failed</td><td>Provider HPI organisation is not appropriate for the Agreement</td></tr><tr><td style=\"white-space:nowrap\">DET055.001<a name=\"claim-decision-reason-cs-DET055.46001\"> </a></td><td>Passed</td><td>NHI number found in our records.</td></tr><tr><td style=\"white-space:nowrap\">DET055.002<a name=\"claim-decision-reason-cs-DET055.46002\"> </a></td><td>Failed</td><td>NHI number cannot be found in our records.</td></tr><tr><td style=\"white-space:nowrap\">DET055.004<a name=\"claim-decision-reason-cs-DET055.46004\"> </a></td><td>Passed</td><td>NHI number validation passes for health service user.</td></tr><tr><td style=\"white-space:nowrap\">DET055.018<a name=\"claim-decision-reason-cs-DET055.46018\"> </a></td><td>Passed</td><td>Patient is eligible for subsidised healthcare</td></tr><tr><td style=\"white-space:nowrap\">DET055.019<a name=\"claim-decision-reason-cs-DET055.46019\"> </a></td><td>Failed</td><td>Patient is not eligible for subsidised healthcare</td></tr><tr><td style=\"white-space:nowrap\">DET041.088<a name=\"claim-decision-reason-cs-DET041.46088\"> </a></td><td>Passed</td><td>Date of Service is earlier than or equal to Claim Date.</td></tr><tr><td style=\"white-space:nowrap\">DET041.087<a name=\"claim-decision-reason-cs-DET041.46087\"> </a></td><td>Failed</td><td>Date of Service is later than Claim Date.</td></tr><tr><td style=\"white-space:nowrap\">DET020.003<a name=\"claim-decision-reason-cs-DET020.46003\"> </a></td><td>Passed</td><td>Date of Service falls between Agreement start and end date.</td></tr><tr><td style=\"white-space:nowrap\">DET020.002<a name=\"claim-decision-reason-cs-DET020.46002\"> </a></td><td>Failed</td><td>Date of Service did not occur between the Agreement start and termination dates.</td></tr><tr><td style=\"white-space:nowrap\">DET064.001<a name=\"claim-decision-reason-cs-DET064.46001\"> </a></td><td>Passed</td><td>Record of encounter was found in our system.</td></tr><tr><td style=\"white-space:nowrap\">DET064.002<a name=\"claim-decision-reason-cs-DET064.46002\"> </a></td><td>Failed</td><td>Could not find the encounter with identifier {identifier} in our system.</td></tr><tr><td style=\"white-space:nowrap\">DET064.003<a name=\"claim-decision-reason-cs-DET064.46003\"> </a></td><td>Passed</td><td>Encounter is for the same Patient as the Claim.</td></tr><tr><td style=\"white-space:nowrap\">DET064.004<a name=\"claim-decision-reason-cs-DET064.46004\"> </a></td><td>Failed</td><td>Encounter and Claim do not refer to the same Patient.</td></tr><tr><td style=\"white-space:nowrap\">DET064.005<a name=\"claim-decision-reason-cs-DET064.46005\"> </a></td><td>Passed</td><td>Encounter is for the same Service Date as the Claim Item.</td></tr><tr><td style=\"white-space:nowrap\">DET064.006<a name=\"claim-decision-reason-cs-DET064.46006\"> </a></td><td>Failed</td><td>Encounter and Claim Item have different Service Dates.</td></tr><tr><td style=\"white-space:nowrap\">DET064.007<a name=\"claim-decision-reason-cs-DET064.46007\"> </a></td><td>Passed</td><td>Patient attended the Encounter.</td></tr><tr><td style=\"white-space:nowrap\">DET064.008<a name=\"claim-decision-reason-cs-DET064.46008\"> </a></td><td>Failed</td><td>Cannot claim for an Encounter that did not occur.</td></tr><tr><td style=\"white-space:nowrap\">DET064.009<a name=\"claim-decision-reason-cs-DET064.46009\"> </a></td><td>Passed</td><td>Encounter is only claimed once.</td></tr><tr><td style=\"white-space:nowrap\">DET064.010<a name=\"claim-decision-reason-cs-DET064.46010\"> </a></td><td>Failed</td><td>Encounter cannot be claimed more than once.</td></tr><tr><td style=\"white-space:nowrap\">DET055.005<a name=\"claim-decision-reason-cs-DET055.46005\"> </a></td><td>Failed</td><td>NHI number provided is for a deceased health service user.</td></tr><tr><td style=\"white-space:nowrap\">DET064.011<a name=\"claim-decision-reason-cs-DET064.46011\"> </a></td><td>Passed</td><td>Fee(s) found for purchase unit code and contracted service.</td></tr><tr><td style=\"white-space:nowrap\">DET064.012<a name=\"claim-decision-reason-cs-DET064.46012\"> </a></td><td>Passed</td><td>Purchase unit code not valid for this contracted service - no fee(s) found.</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 "0.4.5"] ; # 
  fhir:name [ fhir:v "ClaimDecisionReasonCS"] ; # 
  fhir:title [ fhir:v "Claim Decision Reason Code System"] ; # 
  fhir:status [ fhir:v "draft"] ; # 
  fhir:date [ fhir:v "2026-03-03T21:51:04+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 validation rule IDs"] ; # 
  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 "31"^^xsd:nonNegativeInteger] ; # 
  fhir:concept ( [
fhir:code [ fhir:v "DET040.014" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "A valid claim date has been provided." ]
  ] [
fhir:code [ fhir:v "DET040.015" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Claim date provided is not valid." ]
  ] [
fhir:code [ fhir:v "DET052.001" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "No duplicate found for this claim" ]
  ] [
fhir:code [ fhir:v "DET052.002" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Claim is a duplicate of claim [Claim Number] received on [Received Date]." ]
  ] [
fhir:code [ fhir:v "DET001.006" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Agreement is valid for {service name} services" ]
  ] [
fhir:code [ fhir:v "DET001.001" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Agreement number provided cannot be found in our records" ]
  ] [
fhir:code [ fhir:v "DET001.007" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Agreement is not valid for {service name} services" ]
  ] [
fhir:code [ fhir:v "DET063.003" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Provider HPI organisation is appropriate for the Agreement" ]
  ] [
fhir:code [ fhir:v "DET063.004" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Provider HPI organisation is not appropriate for the Agreement" ]
  ] [
fhir:code [ fhir:v "DET055.001" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "NHI number found in our records." ]
  ] [
fhir:code [ fhir:v "DET055.002" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "NHI number cannot be found in our records." ]
  ] [
fhir:code [ fhir:v "DET055.004" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "NHI number validation passes for health service user." ]
  ] [
fhir:code [ fhir:v "DET055.018" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Patient is eligible for subsidised healthcare" ]
  ] [
fhir:code [ fhir:v "DET055.019" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Patient is not eligible for subsidised healthcare" ]
  ] [
fhir:code [ fhir:v "DET041.088" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Date of Service is earlier than or equal to Claim Date." ]
  ] [
fhir:code [ fhir:v "DET041.087" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Date of Service is later than Claim Date." ]
  ] [
fhir:code [ fhir:v "DET020.003" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Date of Service falls between Agreement start and end date." ]
  ] [
fhir:code [ fhir:v "DET020.002" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Date of Service did not occur between the Agreement start and termination dates." ]
  ] [
fhir:code [ fhir:v "DET064.001" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Record of encounter was found in our system." ]
  ] [
fhir:code [ fhir:v "DET064.002" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Could not find the encounter with identifier {identifier} in our system." ]
  ] [
fhir:code [ fhir:v "DET064.003" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Encounter is for the same Patient as the Claim." ]
  ] [
fhir:code [ fhir:v "DET064.004" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Encounter and Claim do not refer to the same Patient." ]
  ] [
fhir:code [ fhir:v "DET064.005" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Encounter is for the same Service Date as the Claim Item." ]
  ] [
fhir:code [ fhir:v "DET064.006" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Encounter and Claim Item have different Service Dates." ]
  ] [
fhir:code [ fhir:v "DET064.007" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Patient attended the Encounter." ]
  ] [
fhir:code [ fhir:v "DET064.008" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Cannot claim for an Encounter that did not occur." ]
  ] [
fhir:code [ fhir:v "DET064.009" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Encounter is only claimed once." ]
  ] [
fhir:code [ fhir:v "DET064.010" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "Encounter cannot be claimed more than once." ]
  ] [
fhir:code [ fhir:v "DET055.005" ] ;
fhir:display [ fhir:v "Failed" ] ;
fhir:definition [ fhir:v "NHI number provided is for a deceased health service user." ]
  ] [
fhir:code [ fhir:v "DET064.011" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Fee(s) found for purchase unit code and contracted service." ]
  ] [
fhir:code [ fhir:v "DET064.012" ] ;
fhir:display [ fhir:v "Passed" ] ;
fhir:definition [ fhir:v "Purchase unit code not valid for this contracted service - no fee(s) found." ]
  ] ) . #