Claim request

The request for payment once treatment is done. The same Claim as the preauthorisation with use set to claim, carrying the finalised dates, bill and documents.

Sent on /v1/claim/submit, answered on /v1/claim/on_submit, workflow 15.

The bundle​

Elements​

1. Claim​

NRCeS profile: Claim.

2. Patient​

NRCeS profile: Patient.

3. Organization (prov)​

NRCeS profile: Organization.

4. Organization (pay)​

NRCeS profile: Organization.

5. Coverage​

NRCeS profile: Coverage.

6. Practitioner​

NRCeS profile: Practitioner.

7. Procedure​

NRCeS profile: Procedure.

Rules​

1. What a claim adds​

The final bill under MB and the discharge summary under HDS, with the implant invoice, the operation notes and the signed claim form where the plan asks for them.

2. The stay​

billablePeriod carries the admission and the discharge.

3. Sequences may have gaps​

Map supporting information by sequence and resolve item.informationSequence through the map.

4. The amount​

May not exceed what the preauthorisation approved.

5. Cyclic treatment​

One supporting-info entry per cycle, with timingPeriod, listed in the item's informationSequence, its record referenced from valueReference.

6. Newborn​

The parent stays the primary Patient; the child is a second Patient linked with link.type refer, with gender and birth date, and a proof of birth under category DOB, code BCF or DCB.

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​

Resources​

• PMJAY adds 4 QuestionnaireResponse.

QuestionnaireResponse​

Elements PMJAY adds​

What PMJAY specifies​

• Dates ride as supporting information: the stay under category ONS, code ADDD, the encounter under OTH, code EDT, and the surgery under code PSP, each as a valueString in +05:30.
• Discharge types DTH, DTM, LAMA and DAMA under category DIS, with the stage, before, during or after surgery, as the valueString.
• LAMA or DAMA before or during surgery voids the approved packages: one item LM100, quantity the days admitted, capped by the package's los. After surgery the package stays billable.
• A death records its date under category ONS, code DTM.
• The discharge consent and the other policy questionnaires ride as QuestionnaireResponse resources, each referenced from a supportingInfo entry.

What PMJAY requires​

• Send the claim under the preauthorisation's own number. Refused with ERR-PYR-CLM-007 otherwise.
• The discharge status under DIS and the admission and discharge dates. The claim is refused without them.
• Bill the package alone, at the whole amount. Room rent, consultations and investigations are not items.
• A fresh biometric token at discharge, or the plan's Discharge Consent questionnaire answered. Refused with PAYR-1363 otherwise.
• LM100 as the single procedure on LAMA or DAMA before or during surgery (PAYR-1362), and the death date under ONS / DTM (PAYR-1096).
• Each cycle's timingPeriod matches the biometric capture for that cycle.

Use cases, APIs and data elements​

B5 Submit claim (provider)​

Reimbursement after discharge. The amount may not exceed what the pre-authorisation approved. The acknowledgement on 25 brings the payer's case number. PMJAY takes a claim query answer on 161 only; 151, 19 and 16 are refused with PAYR-1321.

Request headers

Workflow codes

Data elements

NRCeS profiles: Claim, Patient, Coverage, Organization, Practitioner.

D9 Submit claim (pmjay)​

There is no discharge submission: the claim asserts the discharge and carries its details. Four dates, the discharge type under category DIS with the stage as its value, a fresh biometric token, and LM100 as the single procedure in place of the approved items on a LAMA or DAMA discharge before or during surgery. The amount may not exceed what was approved.

Request headers

Workflow codes

Data elements

NRCeS profiles: Claim, Patient, Organization, Practitioner.