Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
: Claim Decision Reason Code System - TTL Representation
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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\">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>"^^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 "0.4.1"] ; #
fhir:name [ fhir:v "ClaimDecisionReasonCS"] ; #
fhir:title [ fhir:v "Claim Decision Reason Code System"] ; #
fhir:status [ fhir:v "draft"] ; #
fhir:date [ fhir:v "2025-08-31T13:33:02+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 FHIR R5 claim-decision-reason"] ; #
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 "5"^^xsd:nonNegativeInteger] ; #
fhir:concept ( [
fhir:code [ fhir:v "0001" ] ;
fhir:display [ fhir:v "Not medically necessary" ] ;
fhir:definition [ fhir:v "The payer has determined this product, service, or procedure as not medically necessary." ]
] [
fhir:code [ fhir:v "0002" ] ;
fhir:display [ fhir:v "Prior authorization not obtained" ] ;
fhir:definition [ fhir:v "Prior authorization was not obtained prior to providing the product, service, or procedure." ]
] [
fhir:code [ fhir:v "0003" ] ;
fhir:display [ fhir:v "Provider out-of-network" ] ;
fhir:definition [ fhir:v "This provider is considered out-of-network by the payer for this plan." ]
] [
fhir:code [ fhir:v "0004" ] ;
fhir:display [ fhir:v "Service inconsistent with patient age" ] ;
fhir:definition [ fhir:v "The payer has determined this product, service, or procedure is not consistent with the patient's age." ]
] [
fhir:code [ fhir:v "0005" ] ;
fhir:display [ fhir:v "Benefit limits exceeded" ] ;
fhir:definition [ fhir:v "The patient or subscriber benefit's have been exceeded." ]
] ) . #
