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