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

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 - JSON Representation

Draft as of 2026-03-03

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    {
      "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\">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>"
      },
      "url" : "https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs",
      "version" : "0.4.5",
      "name" : "ClaimDecisionReasonCS",
      "title" : "Claim Decision Reason Code System",
      "status" : "draft",
      "date" : "2026-03-03T21:51:04+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 validation rule IDs",
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "urn:iso:std:iso:3166",
              "code" : "NZ",
              "display" : "New Zealand"
            }
          ]
        }
      ],
      "caseSensitive" : true,
      "content" : "complete",
      "count" : 31,
      "concept" : [
        {
          "code" : "DET040.014",
          "display" : "Passed",
          "definition" : "A valid claim date has been provided."
        },
        {
          "code" : "DET040.015",
          "display" : "Failed",
          "definition" : "Claim date provided is not valid."
        },
        {
          "code" : "DET052.001",
          "display" : "Passed",
          "definition" : "No duplicate found for this claim"
        },
        {
          "code" : "DET052.002",
          "display" : "Failed",
          "definition" : "Claim is a duplicate of claim [Claim Number] received on [Received Date]."
        },
        {
          "code" : "DET001.006",
          "display" : "Passed",
          "definition" : "Agreement is valid for {service name} services"
        },
        {
          "code" : "DET001.001",
          "display" : "Failed",
          "definition" : "Agreement number provided cannot be found in our records"
        },
        {
          "code" : "DET001.007",
          "display" : "Failed",
          "definition" : "Agreement is not valid for {service name} services"
        },
        {
          "code" : "DET063.003",
          "display" : "Passed",
          "definition" : "Provider HPI organisation is appropriate for the Agreement"
        },
        {
          "code" : "DET063.004",
          "display" : "Failed",
          "definition" : "Provider HPI organisation is not appropriate for the Agreement"
        },
        {
          "code" : "DET055.001",
          "display" : "Passed",
          "definition" : "NHI number found in our records."
        },
        {
          "code" : "DET055.002",
          "display" : "Failed",
          "definition" : "NHI number cannot be found in our records."
        },
        {
          "code" : "DET055.004",
          "display" : "Passed",
          "definition" : "NHI number validation passes for health service user."
        },
        {
          "code" : "DET055.018",
          "display" : "Passed",
          "definition" : "Patient is eligible for subsidised healthcare"
        },
        {
          "code" : "DET055.019",
          "display" : "Failed",
          "definition" : "Patient is not eligible for subsidised healthcare"
        },
        {
          "code" : "DET041.088",
          "display" : "Passed",
          "definition" : "Date of Service is earlier than or equal to Claim Date."
        },
        {
          "code" : "DET041.087",
          "display" : "Failed",
          "definition" : "Date of Service is later than Claim Date."
        },
        {
          "code" : "DET020.003",
          "display" : "Passed",
          "definition" : "Date of Service falls between Agreement start and end date."
        },
        {
          "code" : "DET020.002",
          "display" : "Failed",
          "definition" : "Date of Service did not occur between the Agreement start and termination dates."
        },
        {
          "code" : "DET064.001",
          "display" : "Passed",
          "definition" : "Record of encounter was found in our system."
        },
        {
          "code" : "DET064.002",
          "display" : "Failed",
          "definition" : "Could not find the encounter with identifier {identifier} in our system."
        },
        {
          "code" : "DET064.003",
          "display" : "Passed",
          "definition" : "Encounter is for the same Patient as the Claim."
        },
        {
          "code" : "DET064.004",
          "display" : "Failed",
          "definition" : "Encounter and Claim do not refer to the same Patient."
        },
        {
          "code" : "DET064.005",
          "display" : "Passed",
          "definition" : "Encounter is for the same Service Date as the Claim Item."
        },
        {
          "code" : "DET064.006",
          "display" : "Failed",
          "definition" : "Encounter and Claim Item have different Service Dates."
        },
        {
          "code" : "DET064.007",
          "display" : "Passed",
          "definition" : "Patient attended the Encounter."
        },
        {
          "code" : "DET064.008",
          "display" : "Failed",
          "definition" : "Cannot claim for an Encounter that did not occur."
        },
        {
          "code" : "DET064.009",
          "display" : "Passed",
          "definition" : "Encounter is only claimed once."
        },
        {
          "code" : "DET064.010",
          "display" : "Failed",
          "definition" : "Encounter cannot be claimed more than once."
        },
        {
          "code" : "DET055.005",
          "display" : "Failed",
          "definition" : "NHI number provided is for a deceased health service user."
        },
        {
          "code" : "DET064.011",
          "display" : "Passed",
          "definition" : "Fee(s) found for purchase unit code and contracted service."
        },
        {
          "code" : "DET064.012",
          "display" : "Passed",
          "definition" : "Purchase unit code not valid for this contracted service - no fee(s) found."
        }
      ]
    }