Cancel, reprocess and shortfall

The post-decision exchanges. All are Task bundles on /v1/task/submit, answered on /v1/task/on_submit, and Task.code with its reason is the only thing that tells them apart.

Cancel​

Sent on /v1/task/submit, workflow PC01.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. Organization (prov)​

NRCeS profile: Organization.

3. Organization (pay)​

NRCeS profile: Organization.

Reprocess​

Sent on /v1/task/submit, workflow 36.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. Organization (prov)​

NRCeS profile: Organization.

3. Organization (pay)​

NRCeS profile: Organization.

Release​

Sent on /v1/task/submit.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. Organization (prov)​

NRCeS profile: Organization.

3. Organization (pay)​

NRCeS profile: Organization.

Cancellation done​

Sent on /v1/task/on_submit, workflow PC02.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. ClaimResponse​

NRCeS profile: ClaimResponse.

The Patient, Organization, Coverage entries are shaped as in the chapters that introduce them.

Reprocess acknowledged​

Sent on /v1/task/on_submit, workflow 37.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. ClaimResponse​

NRCeS profile: ClaimResponse.

The Patient, Organization, Coverage entries are shaped as in the chapters that introduce them.

Rules​

1. Cancel​

Task.code cancel, a reason from ndhm-reason-code (treatmentplanchanged, patientrequest, financialconstraints, alternativetreatment, duplicateclaim, administrativeerror, other), and the inputs claimNumber and intimationNumber.

2. Reprocess​

Task.code reprocess, reason claimrejected for a rejected claim or partialpayment for one paid short, basedOn naming the claim by its CLN identifier, for the member, and the inputs claimNumber and intimationNumber, spelled so.

3. Release​

Task.code release, reason partialpayment, with the claim number and the amount sought as a valueMoney input.

4. Nullify​

The Reprocess sheet of the requests-and-responses workbook gives Task.code on /v1/task/submit as reprocess, cancel, release or nullify, as the use case needs, each with a ClaimNumber input carrying the claim number and Task.status requested; the answer is a Task whose output is the ClaimResponse. The provider sandbox exit checklist names the same four codes. The value sets describe nullify as closing a claim the provider submitted. No sample bundle, reason code or workflow code is published for it.

5. Suspend​

suspend appears only as a code. The value sets list it, glossed "suspend the preauthorization or claim that was submitted by provider", beside the task output claimsuspended. No exchange carries it: no request shape, answer or workflow code is published.

6. The answer​

A Task whose output of type include references a ClaimResponse in the same bundle. Read the result from that ClaimResponse's adjudication reason, not from outcome and not from Task.code. A cancellation is completed with reason cancelled; a reprocess is accepted with the ClaimResponse queued, and the new verdict follows on the claim's own thread.

7. Switch on system and code together​

The Task code systems differ between request and response.

8. A cancelled case still reports money​

Zero the figure yourself once the reason reads cancelled.

PMJAY​

The generic bundle above is what every payer takes, IRDAI-regulated insurers and TPAs included. PMJAY takes it with the changes and requirements below.

What changes in the bundle​

Cancel​

The PMJAY bundle has the same resources, elements and systems as the generic one.

Reprocess​

Elements PMJAY adds​

Systems PMJAY binds differently​

What PMJAY specifies​

• A shortfall is the reprocess Task with reason partialpayment and an amount capped at the difference.
• The reprocess carries the supporting document as a document input with a valueAttachment, and names the member by the PMJAY identifier.
• The reprocess is acknowledged on 37; the new verdict then arrives on the claim's own thread.

What PMJAY requires​

• Cancel is allowed until the claim is raised, and refused once payment has been initiated (PAYR-1257).
• Reprocess once, the moment the rejection arrives, with a supporting document. The Claim Review Committee is final.
• Shortfall only after payment notice 33 has arrived and been acknowledged on 17, once, and never after a reprocess.
• A Task coded status is not taken (PAYR-1018, PAYR-1008). Read where a case stands from the payer service instead.

Use cases, APIs and data elements​

B8 Reprocess or cancel (provider)​

One endpoint, several jobs, told apart by the Task's code and reason: reprocess with claimrejected, shortfall with partialpayment, cancel. A reprocess goes on 36 and is acknowledged on 37; a cancel goes on PC01 and is done on PC02. Both carry the input intimationNumber. A supporting document is mandatory on a reprocess.

Request headers

Workflow codes

Data elements

NRCeS profiles: Task.

D8 Cancel pre-authorisation (pmjay)​

A Task with code cancel, the case number as input and one of seven reasons: treatmentplanchanged, patientrequest, financialconstraints, alternativetreatment, duplicateclaim, administrativeerror, other. Allowed at any point until the claim is raised.

Request headers

Workflow codes

Data elements

NRCeS profiles: Task.

D11 Reprocess a rejected claim (pmjay)​

An appeal, not a resubmission: a Task with code reprocess and reason claimrejected, a supporting document attached, no amount. Raise it the moment the rejection arrives. Once only; the Claim Review Committee is final.

Request headers

Workflow codes

Data elements

NRCeS profiles: Task.

D12 Claim a shortfall (pmjay)​

The same Task with reason partialpayment and an amount capped at the difference, allowed only after payment notice 33 has arrived and been acknowledged with 17. Once only, and never after a reprocess.

Request headers

Workflow codes

Data elements

NRCeS profiles: Task.

C10 Respond to a Task (payer)​

The answer to a reprocess, shortfall or cancel. A cancellation done is PC02 and carries the case's ClaimResponse in its output; a reprocess on 36 is acknowledged on 37 as arbitration. Both payers answer this way.

Request headers

Workflow codes

Data elements

NRCeS profiles: Task.