Preauthorisation request

The first bundle with clinical content. The provider asks the payer to approve a treatment before it is given. The spine is a Claim with use set to preauthorization.

Sent on /v1/preauth/submit, answered on /v1/preauth/on_submit, workflow 12 new, 121 resubmission.

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.

8. QuestionnaireResponse​

Rules​

1. The case number​

Claim.identifier, typed CLN, carries the provider's case number. Every later message on the case, the payer's included, names it.

2. One focal insurance​

Exactly one Claim.insurance[] entry carries focal: true.

3. Items​

Each item links to the care team, diagnosis and procedure by sequence. net is unitPrice times quantity; do not compute with factor. Claim.total equals the sum of the item nets.

4. Documents​

The mandatory document codes are the ones the auth-requirements answer returned. Send each code and display exactly as given.

5. The STG answers​

Each package's STG questionnaire is answered as a QuestionnaireResponse in the bundle, with the linkIds the plan gives.

6. Claim.type​

SNOMED 737481003, Inpatient care management. Payers echo it, some under the ndhm-claim-type ValueSet URL.

7. References to records​

A valueReference may point at the Composition heading an embedded record rather than at a DocumentReference. Follow the reference, then walk the record.

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 1 QuestionnaireResponse.

Elements PMJAY adds​

What PMJAY specifies​

• item.programCode carries AB-PMJAY under ndhm-program-code.
• item.modifier carries the ward tier from the master's stratification codes, and item.category the master's specialty code.
• The Authentication Consent answer is a second QuestionnaireResponse beside the STG answers, with its attachments as valueAttachment and its dates as valueDateTime.
• Document codes are the MAND codes the auth-requirements answer returned.

What PMJAY requires​

• The biometric user token on the request, or the plan's Authentication Consent questionnaire answered as a QuestionnaireResponse. Refused with PAYR-1256 otherwise.
• The STG questionnaire answered for every package that needs one. Refused with PAYR-1254 otherwise.
• Not more than one day before admission, with the registration and admission dates as supporting information.
• One live preauthorisation per beneficiary per hospital. Refused with PAYR-1238 while another is open.
• LM100 is not allowed on a preauthorisation. Refused with PAYR-1270.
• Auto-approval only when this is the first preauthorisation on the case and every package carries ApprovalNotRequired Y.

Use cases, APIs and data elements​

B3 Submit pre-authorisation (provider)​

Permission to treat. A resubmission, an enhancement and a query answer all reuse the same bundle with a new correlation id and the original reference; only the workflow code tells them apart. The acknowledgement on 20 brings the payer's own case number, and the desk files everything under it.

Request headers

Workflow codes

Data elements

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

D4 Submit pre-authorisation (pmjay)​

Not more than one day before admission, with the biometric token or the consent response, the documents the auth-requirements answer asked for, the STG questionnaire for each package, and the registration and admission dates as supporting info. Auto-approved only if it is the first pre-authorisation for the case and every package allows it.

Request headers

Workflow codes

Data elements

NRCeS profiles: Claim, Patient, Organization, Practitioner.

D5 Resubmit pre-authorisation (pmjay)​

Revises an approved or rejected case for a different amount or package. Nullifies every earlier instance; the payer treats it as the new base request.

Request headers

Workflow codes

Data elements

NRCeS profiles: Claim.