Preauthorisation response

The payer's answer, on the provider's /v1/preauth/on_submit callback. A collection bundle whose spine is a ClaimResponse carrying the request's case number. The same shape carries an acknowledgement, an approval, a query and a rejection.

Sent on /v1/preauth/on_submit.

The bundle​

Elements​

ClaimResponse​

NRCeS profile: ClaimResponse.

Patient​

NRCeS profile: Patient.

Organization (pay)​

NRCeS profile: Organization.

Organization (prov)​

NRCeS profile: Organization.

Coverage​

NRCeS profile: Coverage.

The answers​

The same bundle, told apart by the workflow code, outcome and the claim-level adjudication reason.

Rules​

Read outcome with the reason​

outcome complete covers approval and rejection alike. Read it with adjudication[].reason at claim level.

Answer early, decide later​

Acknowledge at once on 20 as response.partial, then decide on 21 or 23 as response.complete, or the exchange retires the correlation before the adjudicator gets to it.

The case number​

preAuthRef carries the payer's own case number. Store it on arrival; later requests on the case name it.

Items by sequence​

Read item adjudication by itemSequence, never by array position. A reduced amount does not force outcome to partial; reconcile the amounts yourself.

Totals​

total[] carries benefit, submitted and eligible. The eligible total names the member and the plan in its id; key on the category and the id together.

disposition is prose​

For a human. Route on outcome and the adjudication codes.

Match on the case number​

Join the response to the request on identifier and preAuthRef, never on the provider identifier or name, which can change shape between request and response.

Adjudication systems​

Some senders bind adjudication categories to a documentation URL. Match on the code.

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​

PMJAY sends this exchange in the generic shape.

What PMJAY specifies​

• A rejection is outcome error with reason rejected and benefit 0. Generic payers send complete with cancelled or rejected. Handle both.
• A query is outcome partial with reason queried, the question as free text in the item adjudication; see the query chapter.
• preAuthRef carries the scheme's case id. It is what the payer service uses to address the case.

What PMJAY requires​

• Store the case reference the moment it arrives. Enhancements, claims and the payer service address the case by it.

Use cases, APIs and data elements​

C5 Respond to pre-authorisation (payer)​

The adjudicated pre-authorisation. The acknowledgement on 20 travels as response.partial and carries the payer's own case number; the decisions travel as response.complete. Read outcome and the adjudication amounts together: complete covers approval and denial alike. Under PMJAY a query is this ClaimResponse on 24 or 241, on the case's own thread.

Request headers

Workflow codes

Data elements

NRCeS profiles: ClaimResponse.