FHIR Implementation Guide for ABDM
7.0.0 - active
FHIR Implementation Guide for ABDM
7.0.0 - active
FHIR Implementation Guide for ABDM - Local Development build (v7.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason | Version: 7.0.0 | |||
| 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
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason version 📦7.0.0
Expansion performed internally based on codesystem Adjudication Reason v7.0.0 (CodeSystem)
This value set contains 45 concepts
| System | Code | Display (en) | Definition | JSON | XML |
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-1 | The claimed service is not covered under the policy, and therefore, the amount is deducted. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-2 | The claimed amount exceeds the maximum coverage limit, leading to a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-3 | The same claim has been submitted more than once, resulting in a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-4 | The claim needs to be coordinated with another insurance policy, leading to a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-5 | The claim lacks essential documentation, leading to a partial deduction until proper documents are provided. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-6 | The claim amount is subject to the policy deductible, leading to a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-7 | The claimant is responsible for a portion of the service cost due to co-payment or coinsurance. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-8 | There is an error in the claim submission, leading to a deduction until the correct information is provided. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-9 | The claim is determined to be fraudulent, leading to a complete/partial deduction of the amount. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-10 | The claimed service is deemed medically unnecessary, leading to a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-11 | The claimant has reached the maximum benefit limit, resulting in a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-12 | The claim was not submitted within the required time frame, leading to a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-13 | The claimed service has already been paid for, leading to a deduction. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-14 | Claim has been rejected due to less tha 24 hours of hospitalization | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-15 | Claim has been rejected as the Package is Reserved to Public Hospital. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-16 | Claim has been closed due to Incomplete submission of documents by hospital after multiple queries. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-17 | Claim has been rejected as there was misrepresentation of bed category booked. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-18 | Claim has been rejected due to Outside Scope of cover (Exclusions as per scheme). | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-19 | Claim has been rejected as the claim was found be False/Fraudulent. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-20 | Claim has been rejected due to mismatch of package and disease/diagnosis/treatment. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-21 | Claim has been rejected due to hospital not empanelled for this specialty. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-22 | Claim has been closed due to non submission of the documents. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-23 | Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-24 | Claim has been closed as the photo of the operative site is not available. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-25 | Claim has been rejected due to apparent manipulation in medical record. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-26 | Claim has been rejected as the hospital expenses have been paid by patient. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-27 | Claim has been closed due missing Pre-Auth patient's photo/post operative photo/After discharge photo. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-28 | Claim has been closed as referral letter mandatory for package selected has not been provided. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-29 | Claim has been rejected as the need for hospitalization was not justified based on the available documents. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | claimError-30 | Claim rejected as the treatment provided does not support the blocked package, request you to book a fresh relevant package. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | covered | Product or Service requested is covered by the policy. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-1 | Pre-Auth has been rejected as the diagnosis is outside Scope of cover (Exclusions as per scheme). | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-2 | Pre-auth has been rejected due to delay in raising enhancement requests. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-3 | Pre-Auth has been rejected as it was found to be False/Fraudulent. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-4 | Pre-Auth has been closed due to delay in preauth Intimation (as per state guidelines). | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-5 | Pre-Auth has been rejected as the Hospital is not empanelled for this specialty. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-6 | Pre- Auth has been rejected due to mismatch in dialysis records. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-7 | Enhancement request rejected as the medical necessity of enhancement request not met. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-8 | Pre-Auth rejected as the medical necessity of ICU bed category not met. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-9 | Pre-Auth has been rejected as the package selected is reserved for public hospital. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-10 | Pre-Auth has been closed due to non submission of mandatory document as per STG. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-11 | Pre-Auth has been rejected as the Surgery was done before Pre-auth Approval. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | preauthError-12 | Pre-auth enhancement rejected due to missing patient photo to depict bed category. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | Queried | Product or Service requested is queried for clarification. | |||
https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason | other | 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 |