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

Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.2) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

CodeSystem: Claim Decision Reason Code System

Official URL: https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs Version: 0.4.2
Draft as of 2025-09-24 Computable Name: ClaimDecisionReasonCS

Code system for claim decision reasons based on FHIR R5 claim-decision-reason

This Code system is referenced in the content logical definition of the following value sets:

This case-sensitive code system https://fhir-ig.digital.health.nz/shared-care/CodeSystem/claim-decision-reason-cs defines the following codes:

CodeDisplayDefinition
0001 Not medically necessary The payer has determined this product, service, or procedure as not medically necessary.
0002 Prior authorization not obtained Prior authorization was not obtained prior to providing the product, service, or procedure.
0003 Provider out-of-network This provider is considered out-of-network by the payer for this plan.
0004 Service inconsistent with patient age The payer has determined this product, service, or procedure is not consistent with the patient's age.
0005 Benefit limits exceeded The patient or subscriber benefit's have been exceeded.