devsofttech_hms_ci4/ABDM_FHIR/definitions.json/CodeSystem-ndhm-adjudication-reason.json

{"resourceType":"CodeSystem","id":"ndhm-adjudication-reason","text":{"status":"generated","div":"<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem ndhm-adjudication-reason</b></p><a name=\"ndhm-adjudication-reason\"> </a><a name=\"hcndhm-adjudication-reason\"> </a><a name=\"ndhm-adjudication-reason-hi-IN\"> </a><p>This case-sensitive code system <code>https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td></tr><tr><td style=\"white-space:nowrap\">claimError-1<a name=\"ndhm-adjudication-reason-claimError-1\"> </a></td><td>The claimed service is not covered under the policy, and therefore, the amount is deducted.</td></tr><tr><td style=\"white-space:nowrap\">claimError-2<a name=\"ndhm-adjudication-reason-claimError-2\"> </a></td><td>The claimed amount exceeds the maximum coverage limit, leading to a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-3<a name=\"ndhm-adjudication-reason-claimError-3\"> </a></td><td>The same claim has been submitted more than once, resulting in a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-4<a name=\"ndhm-adjudication-reason-claimError-4\"> </a></td><td>The claim needs to be coordinated with another insurance policy, leading to a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-5<a name=\"ndhm-adjudication-reason-claimError-5\"> </a></td><td>The claim lacks essential documentation, leading to a partial deduction until proper documents are provided.</td></tr><tr><td style=\"white-space:nowrap\">claimError-6<a name=\"ndhm-adjudication-reason-claimError-6\"> </a></td><td>The claim amount is subject to the policy deductible, leading to a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-7<a name=\"ndhm-adjudication-reason-claimError-7\"> </a></td><td>The claimant is responsible for a portion of the service cost due to co-payment or coinsurance.</td></tr><tr><td style=\"white-space:nowrap\">claimError-8<a name=\"ndhm-adjudication-reason-claimError-8\"> </a></td><td>There is an error in the claim submission, leading to a deduction until the correct information is provided.</td></tr><tr><td style=\"white-space:nowrap\">claimError-9<a name=\"ndhm-adjudication-reason-claimError-9\"> </a></td><td>The claim is determined to be fraudulent, leading to a complete/partial deduction of the amount.</td></tr><tr><td style=\"white-space:nowrap\">claimError-10<a name=\"ndhm-adjudication-reason-claimError-10\"> </a></td><td>The claimed service is deemed medically unnecessary, leading to a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-11<a name=\"ndhm-adjudication-reason-claimError-11\"> </a></td><td>The claimant has reached the maximum benefit limit, resulting in a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-12<a name=\"ndhm-adjudication-reason-claimError-12\"> </a></td><td>The claim was not submitted within the required time frame, leading to a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-13<a name=\"ndhm-adjudication-reason-claimError-13\"> </a></td><td>The claimed service has already been paid for, leading to a deduction.</td></tr><tr><td style=\"white-space:nowrap\">claimError-14<a name=\"ndhm-adjudication-reason-claimError-14\"> </a></td><td>Claim has been rejected due to less tha 24 hours of hospitalization</td></tr><tr><td style=\"white-space:nowrap\">claimError-15<a name=\"ndhm-adjudication-reason-claimError-15\"> </a></td><td>Claim has been rejected as the Package is Reserved to Public Hospital.</td></tr><tr><td style=\"white-space:nowrap\">claimError-16<a name=\"ndhm-adjudication-reason-claimError-16\"> </a></td><td>Claim has been closed due to Incomplete submission of documents by hospital after multiple queries.</td></tr><tr><td style=\"white-space:nowrap\">claimError-17<a name=\"ndhm-adjudication-reason-claimError-17\"> </a></td><td>Claim has been rejected as there was misrepresentation of bed category booked.</td></tr><tr><td style=\"white-space:nowrap\">claimError-18<a name=\"ndhm-adjudication-reason-claimError-18\"> </a></td><td>Claim has been rejected due to Outside Scope of cover (Exclusions as per scheme).</td></tr><tr><td style=\"white-space:nowrap\">claimError-19<a name=\"ndhm-adjudication-reason-claimError-19\"> </a></td><td>Claim has been rejected as the claim was found be False/Fraudulent.</td></tr><tr><td style=\"white-space:nowrap\">claimError-20<a name=\"ndhm-adjudication-reason-claimError-20\"> </a></td><td>Claim has been rejected due to mismatch of package and disease/diagnosis/treatment.</td></tr><tr><td style=\"white-space:nowrap\">claimError-21<a name=\"ndhm-adjudication-reason-claimError-21\"> </a></td><td>Claim has been rejected due to hospital not empanelled for this specialty.</td></tr><tr><td style=\"white-space:nowrap\">claimError-22<a name=\"ndhm-adjudication-reason-claimError-22\"> </a></td><td>Claim has been closed due to non submission of the documents.</td></tr><tr><td style=\"white-space:nowrap\">claimError-23<a name=\"ndhm-adjudication-reason-claimError-23\"> </a></td><td>Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package.</td></tr><tr><td style=\"white-space:nowrap\">claimError-24<a name=\"ndhm-adjudication-reason-claimError-24\"> </a></td><td>Claim has been closed as the photo of the operative site is not available.</td></tr><tr><td style=\"white-space:nowrap\">claimError-25<a name=\"ndhm-adjudication-reason-claimError-25\"> </a></td><td>Claim has been rejected due to apparent manipulation in medical record.</td></tr><tr><td style=\"white-space:nowrap\">claimError-26<a name=\"ndhm-adjudication-reason-claimError-26\"> </a></td><td>Claim has been rejected as the hospital expenses have been paid by patient.</td></tr><tr><td style=\"white-space:nowrap\">claimError-27<a name=\"ndhm-adjudication-reason-claimError-27\"> </a></td><td>Claim has been closed due missing Pre-Auth patient's photo/post operative photo/After discharge photo.</td></tr><tr><td style=\"white-space:nowrap\">claimError-28<a name=\"ndhm-adjudication-reason-claimError-28\"> </a></td><td>Claim has been closed as referral letter mandatory for package selected has not been provided.</td></tr><tr><td style=\"white-space:nowrap\">claimError-29<a name=\"ndhm-adjudication-reason-claimError-29\"> </a></td><td>Claim has been rejected as the need for hospitalization was not justified based on the available documents.</td></tr><tr><td style=\"white-space:nowrap\">claimError-30<a name=\"ndhm-adjudication-reason-claimError-30\"> </a></td><td>Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package.</td></tr><tr><td style=\"white-space:nowrap\">covered<a name=\"ndhm-adjudication-reason-covered\"> </a></td><td>Product or Service requested is covered by the policy.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-1<a name=\"ndhm-adjudication-reason-preauthError-1\"> </a></td><td>Pre-Auth has been rejected as the diagnosis is outside Scope of cover (Exclusions as per scheme).</td></tr><tr><td style=\"white-space:nowrap\">preauthError-2<a name=\"ndhm-adjudication-reason-preauthError-2\"> </a></td><td>Pre-auth has been rejected due to delay in raising enhancement requests.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-3<a name=\"ndhm-adjudication-reason-preauthError-3\"> </a></td><td>Pre-Auth has been rejected as it was found to be False/Fraudulent.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-4<a name=\"ndhm-adjudication-reason-preauthError-4\"> </a></td><td>Pre-Auth has been closed due to delay in preauth Intimation (as per state guidelines).</td></tr><tr><td style=\"white-space:nowrap\">preauthError-5<a name=\"ndhm-adjudication-reason-preauthError-5\"> </a></td><td>Pre-Auth has been rejected as the Hospital is not empanelled for this specialty.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-6<a name=\"ndhm-adjudication-reason-preauthError-6\"> </a></td><td>Pre- Auth has been rejected due to mismatch in dialysis records.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-7<a name=\"ndhm-adjudication-reason-preauthError-7\"> </a></td><td>Enhancement request rejected as the medical necessity of enhancement request not met.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-8<a name=\"ndhm-adjudication-reason-preauthError-8\"> </a></td><td>Pre-Auth rejected as the medical necessity of ICU bed category not met.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-9<a name=\"ndhm-adjudication-reason-preauthError-9\"> </a></td><td>Pre-Auth has been rejected as the package selected is reserved for public hospital.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-10<a name=\"ndhm-adjudication-reason-preauthError-10\"> </a></td><td>Pre-Auth has been closed due to non submission of mandatory document as per STG.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-11<a name=\"ndhm-adjudication-reason-preauthError-11\"> </a></td><td>Pre-Auth has been rejected as the Surgery was done before Pre-auth Approval.</td></tr><tr><td style=\"white-space:nowrap\">preauthError-12<a name=\"ndhm-adjudication-reason-preauthError-12\"> </a></td><td>Pre-auth enhancement rejected due to missing patient photo to depict bed category.</td></tr><tr><td style=\"white-space:nowrap\">Queried<a name=\"ndhm-adjudication-reason-Queried\"> </a></td><td>Product or Service requested is queried for clarification.</td></tr><tr><td style=\"white-space:nowrap\">other<a name=\"ndhm-adjudication-reason-other\"> </a></td><td>Others</td></tr></table></div>"},"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"}]}