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 |
<CodeSystem xmlns="http://hl7.org/fhir">
<id value="ndhm-adjudication-reason"/>
<text>
<status value="generated"/>
<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>
</text>
<url
value="https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason"/>
<version value="6.5.0"/>
<name value="AdjudicationReason"/>
<title value="Adjudication Reason"/>
<status value="draft"/>
<experimental value="false"/>
<date value="2024-09-20"/>
<publisher value="National Resource Center for EHR Standards"/>
<contact>
<name value="National Resource Center for EHR Standards"/>
<telecom>
<system value="url"/>
<value value="https://nrces.in/"/>
</telecom>
</contact>
<description
value="This CodeSystem contains code to captures reasons associated with adjudication of each items while claim processing."/>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="IN"/>
<display value="India"/>
</coding>
</jurisdiction>
<caseSensitive value="true"/>
<content value="complete"/>
<count value="45"/>
<concept>
<code value="claimError-1"/>
<display
value="The claimed service is not covered under the policy, and therefore, the amount is deducted."/>
</concept>
<concept>
<code value="claimError-2"/>
<display
value="The claimed amount exceeds the maximum coverage limit, leading to a deduction."/>
</concept>
<concept>
<code value="claimError-3"/>
<display
value="The same claim has been submitted more than once, resulting in a deduction."/>
</concept>
<concept>
<code value="claimError-4"/>
<display
value="The claim needs to be coordinated with another insurance policy, leading to a deduction."/>
</concept>
<concept>
<code value="claimError-5"/>
<display
value="The claim lacks essential documentation, leading to a partial deduction until proper documents are provided."/>
</concept>
<concept>
<code value="claimError-6"/>
<display
value="The claim amount is subject to the policy deductible, leading to a deduction."/>
</concept>
<concept>
<code value="claimError-7"/>
<display
value="The claimant is responsible for a portion of the service cost due to co-payment or coinsurance."/>
</concept>
<concept>
<code value="claimError-8"/>
<display
value="There is an error in the claim submission, leading to a deduction until the correct information is provided."/>
</concept>
<concept>
<code value="claimError-9"/>
<display
value="The claim is determined to be fraudulent, leading to a complete/partial deduction of the amount."/>
</concept>
<concept>
<code value="claimError-10"/>
<display
value="The claimed service is deemed medically unnecessary, leading to a deduction."/>
</concept>
<concept>
<code value="claimError-11"/>
<display
value="The claimant has reached the maximum benefit limit, resulting in a deduction."/>
</concept>
<concept>
<code value="claimError-12"/>
<display
value="The claim was not submitted within the required time frame, leading to a deduction."/>
</concept>
<concept>
<code value="claimError-13"/>
<display
value="The claimed service has already been paid for, leading to a deduction."/>
</concept>
<concept>
<code value="claimError-14"/>
<display
value="Claim has been rejected due to less tha 24 hours of hospitalization"/>
</concept>
<concept>
<code value="claimError-15"/>
<display
value="Claim has been rejected as the Package is Reserved to Public Hospital."/>
</concept>
<concept>
<code value="claimError-16"/>
<display
value="Claim has been closed due to Incomplete submission of documents by hospital after multiple queries."/>
</concept>
<concept>
<code value="claimError-17"/>
<display
value="Claim has been rejected as there was misrepresentation of bed category booked."/>
</concept>
<concept>
<code value="claimError-18"/>
<display
value="Claim has been rejected due to Outside Scope of cover (Exclusions as per scheme)."/>
</concept>
<concept>
<code value="claimError-19"/>
<display
value="Claim has been rejected as the claim was found be False/Fraudulent."/>
</concept>
<concept>
<code value="claimError-20"/>
<display
value="Claim has been rejected due to mismatch of package and disease/diagnosis/treatment."/>
</concept>
<concept>
<code value="claimError-21"/>
<display
value="Claim has been rejected due to hospital not empanelled for this specialty."/>
</concept>
<concept>
<code value="claimError-22"/>
<display
value="Claim has been closed due to non submission of the documents."/>
</concept>
<concept>
<code value="claimError-23"/>
<display
value="Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package."/>
</concept>
<concept>
<code value="claimError-24"/>
<display
value="Claim has been closed as the photo of the operative site is not available."/>
</concept>
<concept>
<code value="claimError-25"/>
<display
value="Claim has been rejected due to apparent manipulation in medical record."/>
</concept>
<concept>
<code value="claimError-26"/>
<display
value="Claim has been rejected as the hospital expenses have been paid by patient."/>
</concept>
<concept>
<code value="claimError-27"/>
<display
value="Claim has been closed due missing Pre-Auth patient's photo/post operative photo/After discharge photo."/>
</concept>
<concept>
<code value="claimError-28"/>
<display
value="Claim has been closed as referral letter mandatory for package selected has not been provided."/>
</concept>
<concept>
<code value="claimError-29"/>
<display
value="Claim has been rejected as the need for hospitalization was not justified based on the available documents."/>
</concept>
<concept>
<code value="claimError-30"/>
<display
value="Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package."/>
</concept>
<concept>
<code value="covered"/>
<display value="Product or Service requested is covered by the policy."/>
</concept>
<concept>
<code value="preauthError-1"/>
<display
value="Pre-Auth has been rejected as the diagnosis is outside Scope of cover (Exclusions as per scheme)."/>
</concept>
<concept>
<code value="preauthError-2"/>
<display
value="Pre-auth has been rejected due to delay in raising enhancement requests."/>
</concept>
<concept>
<code value="preauthError-3"/>
<display
value="Pre-Auth has been rejected as it was found to be False/Fraudulent."/>
</concept>
<concept>
<code value="preauthError-4"/>
<display
value="Pre-Auth has been closed due to delay in preauth Intimation (as per state guidelines)."/>
</concept>
<concept>
<code value="preauthError-5"/>
<display
value="Pre-Auth has been rejected as the Hospital is not empanelled for this specialty."/>
</concept>
<concept>
<code value="preauthError-6"/>
<display
value="Pre- Auth has been rejected due to mismatch in dialysis records."/>
</concept>
<concept>
<code value="preauthError-7"/>
<display
value="Enhancement request rejected as the medical necessity of enhancement request not met."/>
</concept>
<concept>
<code value="preauthError-8"/>
<display
value="Pre-Auth rejected as the medical necessity of ICU bed category not met."/>
</concept>
<concept>
<code value="preauthError-9"/>
<display
value="Pre-Auth has been rejected as the package selected is reserved for public hospital."/>
</concept>
<concept>
<code value="preauthError-10"/>
<display
value="Pre-Auth has been closed due to non submission of mandatory document as per STG."/>
</concept>
<concept>
<code value="preauthError-11"/>
<display
value="Pre-Auth has been rejected as the Surgery was done before Pre-auth Approval."/>
</concept>
<concept>
<code value="preauthError-12"/>
<display
value="Pre-auth enhancement rejected due to missing patient photo to depict bed category."/>
</concept>
<concept>
<code value="Queried"/>
<display
value="Product or Service requested is queried for clarification."/>
</concept>
<concept>
<code value="other"/>
<display value="Others"/>
</concept>
</CodeSystem>