{"resourceType":"CodeSystem","id":"ndhm-adjudication-reason","text":{"status":"generated","div":"

Generated Narrative: CodeSystem ndhm-adjudication-reason

This case-sensitive code system https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason defines the following codes:

CodeDisplay
claimError-1 The claimed service is not covered under the policy, and therefore, the amount is deducted.
claimError-2 The claimed amount exceeds the maximum coverage limit, leading to a deduction.
claimError-3 The same claim has been submitted more than once, resulting in a deduction.
claimError-4 The claim needs to be coordinated with another insurance policy, leading to a deduction.
claimError-5 The claim lacks essential documentation, leading to a partial deduction until proper documents are provided.
claimError-6 The claim amount is subject to the policy deductible, leading to a deduction.
claimError-7 The claimant is responsible for a portion of the service cost due to co-payment or coinsurance.
claimError-8 There is an error in the claim submission, leading to a deduction until the correct information is provided.
claimError-9 The claim is determined to be fraudulent, leading to a complete/partial deduction of the amount.
claimError-10 The claimed service is deemed medically unnecessary, leading to a deduction.
claimError-11 The claimant has reached the maximum benefit limit, resulting in a deduction.
claimError-12 The claim was not submitted within the required time frame, leading to a deduction.
claimError-13 The claimed service has already been paid for, leading to a deduction.
claimError-14 Claim has been rejected due to less tha 24 hours of hospitalization
claimError-15 Claim has been rejected as the Package is Reserved to Public Hospital.
claimError-16 Claim has been closed due to Incomplete submission of documents by hospital after multiple queries.
claimError-17 Claim has been rejected as there was misrepresentation of bed category booked.
claimError-18 Claim has been rejected due to Outside Scope of cover (Exclusions as per scheme).
claimError-19 Claim has been rejected as the claim was found be False/Fraudulent.
claimError-20 Claim has been rejected due to mismatch of package and disease/diagnosis/treatment.
claimError-21 Claim has been rejected due to hospital not empanelled for this specialty.
claimError-22 Claim has been closed due to non submission of the documents.
claimError-23 Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package.
claimError-24 Claim has been closed as the photo of the operative site is not available.
claimError-25 Claim has been rejected due to apparent manipulation in medical record.
claimError-26 Claim has been rejected as the hospital expenses have been paid by patient.
claimError-27 Claim has been closed due missing Pre-Auth patient's photo/post operative photo/After discharge photo.
claimError-28 Claim has been closed as referral letter mandatory for package selected has not been provided.
claimError-29 Claim has been rejected as the need for hospitalization was not justified based on the available documents.
claimError-30 Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package.
covered Product or Service requested is covered by the policy.
preauthError-1 Pre-Auth has been rejected as the diagnosis is outside Scope of cover (Exclusions as per scheme).
preauthError-2 Pre-auth has been rejected due to delay in raising enhancement requests.
preauthError-3 Pre-Auth has been rejected as it was found to be False/Fraudulent.
preauthError-4 Pre-Auth has been closed due to delay in preauth Intimation (as per state guidelines).
preauthError-5 Pre-Auth has been rejected as the Hospital is not empanelled for this specialty.
preauthError-6 Pre- Auth has been rejected due to mismatch in dialysis records.
preauthError-7 Enhancement request rejected as the medical necessity of enhancement request not met.
preauthError-8 Pre-Auth rejected as the medical necessity of ICU bed category not met.
preauthError-9 Pre-Auth has been rejected as the package selected is reserved for public hospital.
preauthError-10 Pre-Auth has been closed due to non submission of mandatory document as per STG.
preauthError-11 Pre-Auth has been rejected as the Surgery was done before Pre-auth Approval.
preauthError-12 Pre-auth enhancement rejected due to missing patient photo to depict bed category.
Queried Product or Service requested is queried for clarification.
other Others
"},"url":"https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason","version":"6.5.0","name":"AdjudicationReason","title":"Adjudication Reason","status":"draft","experimental":false,"date":"2024-09-20","publisher":"National Resource Center for EHR Standards","contact":[{"name":"National Resource Center for EHR Standards","telecom":[{"system":"url","value":"https://nrces.in/"}]}],"description":"This CodeSystem contains code to captures reasons associated with adjudication of each items while claim processing.","jurisdiction":[{"coding":[{"system":"urn:iso:std:iso:3166","code":"IN","display":"India"}]}],"caseSensitive":true,"content":"complete","count":45,"concept":[{"code":"claimError-1","display":"The claimed service is not covered under the policy, and therefore, the amount is deducted."},{"code":"claimError-2","display":"The claimed amount exceeds the maximum coverage limit, leading to a deduction."},{"code":"claimError-3","display":"The same claim has been submitted more than once, resulting in a deduction."},{"code":"claimError-4","display":"The claim needs to be coordinated with another insurance policy, leading to a deduction."},{"code":"claimError-5","display":"The claim lacks essential documentation, leading to a partial deduction until proper documents are provided."},{"code":"claimError-6","display":"The claim amount is subject to the policy deductible, leading to a deduction."},{"code":"claimError-7","display":"The claimant is responsible for a portion of the service cost due to co-payment or coinsurance."},{"code":"claimError-8","display":"There is an error in the claim submission, leading to a deduction until the correct information is provided."},{"code":"claimError-9","display":"The claim is determined to be fraudulent, leading to a complete/partial deduction of the amount."},{"code":"claimError-10","display":"The claimed service is deemed medically unnecessary, leading to a deduction."},{"code":"claimError-11","display":"The claimant has reached the maximum benefit limit, resulting in a deduction."},{"code":"claimError-12","display":"The claim was not submitted within the required time frame, leading to a deduction."},{"code":"claimError-13","display":"The claimed service has already been paid for, leading to a deduction."},{"code":"claimError-14","display":"Claim has been rejected due to less tha 24 hours of hospitalization"},{"code":"claimError-15","display":"Claim has been rejected as the Package is Reserved to Public Hospital."},{"code":"claimError-16","display":"Claim has been closed due to Incomplete submission of documents by hospital after multiple queries."},{"code":"claimError-17","display":"Claim has been rejected as there was misrepresentation of bed category booked."},{"code":"claimError-18","display":"Claim has been rejected due to Outside Scope of cover (Exclusions as per scheme)."},{"code":"claimError-19","display":"Claim has been rejected as the claim was found be False/Fraudulent."},{"code":"claimError-20","display":"Claim has been rejected due to mismatch of package and disease/diagnosis/treatment."},{"code":"claimError-21","display":"Claim has been rejected due to hospital not empanelled for this specialty."},{"code":"claimError-22","display":"Claim has been closed due to non submission of the documents."},{"code":"claimError-23","display":"Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package."},{"code":"claimError-24","display":"Claim has been closed as the photo of the operative site is not available."},{"code":"claimError-25","display":"Claim has been rejected due to apparent manipulation in medical record."},{"code":"claimError-26","display":"Claim has been rejected as the hospital expenses have been paid by patient."},{"code":"claimError-27","display":"Claim has been closed due missing Pre-Auth patient's photo/post operative photo/After discharge photo."},{"code":"claimError-28","display":"Claim has been closed as referral letter mandatory for package selected has not been provided."},{"code":"claimError-29","display":"Claim has been rejected as the need for hospitalization was not justified based on the available documents."},{"code":"claimError-30","display":"Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package."},{"code":"covered","display":"Product or Service requested is covered by the policy."},{"code":"preauthError-1","display":"Pre-Auth has been rejected as the diagnosis is outside Scope of cover (Exclusions as per scheme)."},{"code":"preauthError-2","display":"Pre-auth has been rejected due to delay in raising enhancement requests."},{"code":"preauthError-3","display":"Pre-Auth has been rejected as it was found to be False/Fraudulent."},{"code":"preauthError-4","display":"Pre-Auth has been closed due to delay in preauth Intimation (as per state guidelines)."},{"code":"preauthError-5","display":"Pre-Auth has been rejected as the Hospital is not empanelled for this specialty."},{"code":"preauthError-6","display":"Pre- Auth has been rejected due to mismatch in dialysis records."},{"code":"preauthError-7","display":"Enhancement request rejected as the medical necessity of enhancement request not met."},{"code":"preauthError-8","display":"Pre-Auth rejected as the medical necessity of ICU bed category not met."},{"code":"preauthError-9","display":"Pre-Auth has been rejected as the package selected is reserved for public hospital."},{"code":"preauthError-10","display":"Pre-Auth has been closed due to non submission of mandatory document as per STG."},{"code":"preauthError-11","display":"Pre-Auth has been rejected as the Surgery was done before Pre-auth Approval."},{"code":"preauthError-12","display":"Pre-auth enhancement rejected due to missing patient photo to depict bed category."},{"code":"Queried","display":"Product or Service requested is queried for clarification."},{"code":"other","display":"Others"}]}