Insurance plan response, package-based

The shape government schemes send, and PMJAY sends throughout. A package is a named procedure at a fixed, all-inclusive rate. The plan carries every package the hospital may bill and the rules that govern each one. Everything in this chapter is what PMJAY specifies.

The bundle​

Elements​

NRCeS profile: InsurancePlan.

Claim-Condition flags​

Supporting-information requirements​

5 of the requirements link a questionnaire through documentationUrl.

Questionnaires​

Rules​

1. Two parallel structures​

coverage[] carries the rules: flags, document requirements, questionnaire links and limit[] rates. plan[].specificCost[] carries the money: cost[] lines by type. Both hold the same package codes. Index both by package code and join; neither is complete alone.

2. Categories​

coverage[].type and specificCost[].category bind to https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory. Codes beginning S are surgical, M medical.

3. Flags are strings​

Every flag except ParentProcedure is a valueString. "N" is truthy in most languages; compare against the literal "Y".

4. Cost lines​

Procedure is the base package rate. Stratification is the rate for a ward tier, named in cost.qualifiers[]. Implant is added over the package rate.

5. A zero base rate​

A base limit of 0 means the payable amount is set entirely by the ward tier chosen. It is not missing data. Never submit a zero-value item.

6. Document requirements come in two shapes​

Nested, one sub-extension per document, and flat, with category, code and documentationUrl directly under the extension. Recurse, or one shape is silently dropped.

7. Where the question is​

Policy-level questionnaires put the question in item.text, STG questionnaires in item.prefix. Read text and fall back to prefix.

8. Implant codes repeat​

Once per parent procedure they may accompany. Key on the package code with its parent, or on the element id.

9. Extension urls change form​

The absolute https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition and the relative claim-condition both occur. Match on the last segment.

PMJAY​

This is the PMJAY shape; the rules above are PMJAY's.