FHIR Implementation Guide for ABDM
6.5.0 - active
FHIR Implementation Guide for ABDM
6.5.0 - active
This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Draft as of 2024-09-20 |
@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 "ndhm-adjudication-reason"] ; # 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 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>"^^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" ] ] ) . #
IG © 2024+ National Resource Center for EHR Standards. Package ndhm.in#6.5.0 based on FHIR 4.0.1. Generated 2025-05-08
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