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
| Official URL: https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason | Version: 6.5.0 | |||
| Draft as of 2023-11-28 | Computable Name: AdjudicationReason | |||
This ValueSet contains a set of codes to captures reasons associated with adjudication of each Product/service while claim processing.
References
Generated Narrative: ValueSet ndhm-adjudication-reason
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason
Generated Narrative: ValueSet
Expansion done internally based on codesystem Adjudication Reason v6.5.0 (CodeSystem)
This value set contains 45 concepts
| Code | System | Display |
| claimError-1 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claimed service is not covered under the policy, and therefore, the amount is deducted. |
| claimError-2 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claimed amount exceeds the maximum coverage limit, leading to a deduction. |
| claimError-3 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The same claim has been submitted more than once, resulting in a deduction. |
| claimError-4 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claim needs to be coordinated with another insurance policy, leading to a deduction. |
| claimError-5 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claim lacks essential documentation, leading to a partial deduction until proper documents are provided. |
| claimError-6 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claim amount is subject to the policy deductible, leading to a deduction. |
| claimError-7 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claimant is responsible for a portion of the service cost due to co-payment or coinsurance. |
| claimError-8 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | There is an error in the claim submission, leading to a deduction until the correct information is provided. |
| claimError-9 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claim is determined to be fraudulent, leading to a complete/partial deduction of the amount. |
| claimError-10 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claimed service is deemed medically unnecessary, leading to a deduction. |
| claimError-11 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claimant has reached the maximum benefit limit, resulting in a deduction. |
| claimError-12 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claim was not submitted within the required time frame, leading to a deduction. |
| claimError-13 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | The claimed service has already been paid for, leading to a deduction. |
| claimError-14 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected due to less tha 24 hours of hospitalization |
| claimError-15 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected as the Package is Reserved to Public Hospital. |
| claimError-16 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been closed due to Incomplete submission of documents by hospital after multiple queries. |
| claimError-17 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected as there was misrepresentation of bed category booked. |
| claimError-18 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected due to Outside Scope of cover (Exclusions as per scheme). |
| claimError-19 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected as the claim was found be False/Fraudulent. |
| claimError-20 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected due to mismatch of package and disease/diagnosis/treatment. |
| claimError-21 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected due to hospital not empanelled for this specialty. |
| claimError-22 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been closed due to non submission of the documents. |
| claimError-23 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package. |
| claimError-24 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been closed as the photo of the operative site is not available. |
| claimError-25 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected due to apparent manipulation in medical record. |
| claimError-26 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected as the hospital expenses have been paid by patient. |
| claimError-27 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been closed due missing Pre-Auth patient's photo/post operative photo/After discharge photo. |
| claimError-28 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been closed as referral letter mandatory for package selected has not been provided. |
| claimError-29 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim has been rejected as the need for hospitalization was not justified based on the available documents. |
| claimError-30 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package. |
| covered | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Product or Service requested is covered by the policy. |
| preauthError-1 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been rejected as the diagnosis is outside Scope of cover (Exclusions as per scheme). |
| preauthError-2 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-auth has been rejected due to delay in raising enhancement requests. |
| preauthError-3 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been rejected as it was found to be False/Fraudulent. |
| preauthError-4 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been closed due to delay in preauth Intimation (as per state guidelines). |
| preauthError-5 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been rejected as the Hospital is not empanelled for this specialty. |
| preauthError-6 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre- Auth has been rejected due to mismatch in dialysis records. |
| preauthError-7 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Enhancement request rejected as the medical necessity of enhancement request not met. |
| preauthError-8 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth rejected as the medical necessity of ICU bed category not met. |
| preauthError-9 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been rejected as the package selected is reserved for public hospital. |
| preauthError-10 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been closed due to non submission of mandatory document as per STG. |
| preauthError-11 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-Auth has been rejected as the Surgery was done before Pre-auth Approval. |
| preauthError-12 | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Pre-auth enhancement rejected due to missing patient photo to depict bed category. |
| Queried | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Product or Service requested is queried for clarification. |
| other | https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Others |
Explanation of the columns that may appear on this page:
| Level | A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies |
| System | The source of the definition of the code (when the value set draws in codes defined elsewhere) |
| Code | The code (used as the code in the resource instance) |
| Display | The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application |
| Definition | An explanation of the meaning of the concept |
| Comments | Additional notes about how to use the code |