{ "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" }] }