app/data/adjudication_rules.md

OPD Claim Adjudication Rules

Overview

This document outlines the rules and logic for adjudicating (approving/rejecting) OPD insurance claims. The system should evaluate claims based on these rules in the specified order.

Adjudication Flow

Step 1: Basic Eligibility Check

• Policy Status: Policy must be active on the date of treatment
• Waiting Period: Check if waiting periods have been satisfied
• Member Verification: Claimant must be a covered member (employee/dependent)

Step 2: Document Validation

All submitted documents must meet these criteria:

• Legibility: Documents must be clear and readable
• Completeness: All required fields must be visible
• Authenticity:
  • Doctor's registration number must be valid (format: [State Code]/[Number]/[Year])
  • Hospital/Clinic registration must be verifiable
  • Bills must have proper headers and stamps
• Date Consistency: All documents must have matching treatment dates
• Patient Details: Name and age must match policy records (minor variations acceptable)

Step 3: Coverage Verification

Check if the treatment/service is covered:

• Compare against covered services list
• Verify it's not in exclusions list
• Check for pre-authorization requirements

Step 4: Limit Validation

Verify claim amount against applicable limits:

1. Annual Limit: Total claims YTD + current claim ≤ Annual limit
2. Sub-limits: Category-specific limits (consultation, pharmacy, etc.)
3. Per-claim Limit: Single claim cannot exceed per-claim limit
4. Co-payment Calculation: Apply co-pay percentages where applicable

Step 5: Medical Necessity Review

Evaluate if treatment was medically necessary:

• Diagnosis must justify the treatment
• Prescription must align with diagnosis
• Test results must support the diagnosis (if applicable)
• Treatment must follow standard medical protocols

Approval Conditions

A claim is APPROVED when ALL of the following are true:

• ✅ Policy is active and waiting period satisfied
• ✅ All required documents are submitted and valid
• ✅ Treatment is covered under policy
• ✅ Claim amount is within limits (after co-pay)
• ✅ Medical necessity is established
• ✅ No fraud indicators detected

Rejection Reasons

A claim is REJECTED if ANY of the following apply:

Category 1: Eligibility Issues

• POLICY_INACTIVE: Policy not active on treatment date
• WAITING_PERIOD: Treatment during waiting period
• MEMBER_NOT_COVERED: Claimant not found in policy records

Category 2: Documentation Issues

• MISSING_DOCUMENTS: Required documents not submitted
• ILLEGIBLE_DOCUMENTS: Documents not readable
• INVALID_PRESCRIPTION: Prescription missing or invalid
• DOCTOR_REG_INVALID: Doctor registration number invalid/missing
• DATE_MISMATCH: Document dates don't match
• PATIENT_MISMATCH: Patient details don't match records

Category 3: Coverage Issues

• SERVICE_NOT_COVERED: Treatment/service not covered
• EXCLUDED_CONDITION: Condition in exclusions list
• PRE_AUTH_MISSING: Pre-authorization required but not obtained

Category 4: Limit Issues

• ANNUAL_LIMIT_EXCEEDED: Annual limit exhausted
• SUB_LIMIT_EXCEEDED: Category sub-limit exceeded
• PER_CLAIM_EXCEEDED: Single claim limit exceeded

Category 5: Medical Issues

• NOT_MEDICALLY_NECESSARY: Treatment not justified by diagnosis
• EXPERIMENTAL_TREATMENT: Experimental/unproven treatment
• COSMETIC_PROCEDURE: Cosmetic/aesthetic procedure

Category 6: Process Issues

• LATE_SUBMISSION: Submitted after 30-day deadline
• DUPLICATE_CLAIM: Same treatment already claimed
• BELOW_MIN_AMOUNT: Claim below ₹500 minimum

Special Scenarios

1. Partial Approval

Claims can be partially approved when:

• Part of the treatment is covered, part is not
• Claim exceeds limits (approve up to limit)
• Co-payment applies

2. Refer for Manual Review

Send for human review when:

• Fraud indicators detected (unusual patterns, modified documents)
• High-value claims (>₹25,000)
• Complex medical conditions
• System confidence <70%
• Member appeals automated decision

3. Network vs Non-Network

• Network providers: Apply network discounts, cashless possible
• Non-network: Full payment by member, standard reimbursement

Fraud Indicators

Watch for these red flags:

• Multiple claims from same provider on same day
• Unusually high frequency of claims
• Bills with suspicious alterations
• Diagnosis not matching age/gender
• Duplicate bills across different dates
• Provider not registered/blacklisted

Decision Output Format

Every decision should include:

{
  "claim_id": "CLM_XXXXX",
  "decision": "APPROVED/REJECTED/PARTIAL/MANUAL_REVIEW",
  "approved_amount": 0000,
  "rejection_reasons": [],
  "confidence_score": 0.95,
  "notes": "Additional observations",
  "next_steps": "What the claimant should do"
}

Priority Rules

When multiple rules conflict:

1. Safety first (reject suspicious/fraudulent claims)
2. Policy exclusions override everything
3. Hard limits cannot be exceeded
4. Medical necessity is mandatory
5. When in doubt, refer for manual review