{
  "description": "This CodeSystem contains code to captures reasons associated with adjudication of each items while claim processing.",
  "_filename": "CodeSystem-ndhm-adjudication-reason.json",
  "package_name": "ndhm.in",
  "date": "2024-09-20",
  "publisher": "National Resource Center for EHR Standards",
  "jurisdiction": [ {
    "coding": [ {
      "code": "IN",
      "system": "urn:iso:std:iso:3166",
      "display": "India"
    } ]
  } ],
  "content": "complete",
  "name": "AdjudicationReason",
  "type": null,
  "experimental": "false",
  "resourceType": "CodeSystem",
  "title": "Adjudication Reason",
  "package_version": "6.5.0",
  "status": "draft",
  "id": "2deeb0c4-c8d1-433e-9b60-e52b63402e80",
  "kind": null,
  "count": 45,
  "url": "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-adjudication-reason",
  "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"
  } ],
  "caseSensitive": true,
  "version": "6.5.0",
  "contact": [ {
    "name": "National Resource Center for EHR Standards",
    "telecom": [ {
      "value": "https://nrces.in/",
      "system": "url"
    } ]
  } ]
}