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 - XML Representation

Draft as of 2026-03-03

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