Claims & Reimbursement¶

2.1. Claim Lifecycle¶

1. Registration: Patient registration and eligibility check.
2. Encounter documentation: Clinical documentation of the visit.
3. Coding: Assigning ICD-10-AM and ACHI codes.
4. Submission: Sending the claim via NPHIES.
5. Adjudication: Payer review process.
6. Rejection: Handling denied claims.
7. Resubmission: Correcting and resending claims.
8. Settlement: Final payment and reconciliation.

2.2. Rejection Classification¶

• Administrative: Missing info, invalid ID.
• Clinical: Medical necessity, inconsistent diagnosis.
• Eligibility: Expired coverage, uncovered service.
• Technical: FHIR validation errors.
• Coding-related: Incorrect codes or modifiers.
• Duplicate: Claim already submitted.

2.3. Resubmission Best Practices¶

• Validate FHIR bundle
• Correct coding
• Add missing attachments
• Include clinical justification
• Follow payer-specific rules (Bupa/Tawuniya/GlobeMed)