FHIR IG Statistics: CodeSystem/ndhm-adjudication-reason

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Source

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