NHCX Fraud Detection Framework

Provider Ecosystem

NHCX / CFDF Core Engine

Payer / Adjudication

ABDM / Regulatory Layer

Patient / Citizen

Fraud Flag / Alert

          ← Provider Ecosystem

Ingestion Layer

Clinical Document Pipeline

Discharge summaries, lab reports, radiology, pharmacy Rx, and itemized hospital bills uploaded via provider portal.

FHIR DocumentReference MEDCAT NLP

Terminology Mapping

Diagnosis & Procedure Coding

Extracted diagnoses mapped to ICD-10-TM / SNOMED CT. Diagnostics coded to LOINC. Procedures mapped to CPT / HCPCS.

SNOMED CT ICD-10-TM LOINC

Pre-Submission Hook

CDS Hooks: claim-submit

Pre-submission CDS cards delivered to provider workflow identifying duplicate risk, documentation gaps, and coverage optimization.

CDS Hooks 2.0 SMART on FHIR

Bundle Construction

FHIR ClaimBundle Assembly

Validated outputs from PS01–PS03 consolidated into NHCX-conformant FHIR Claim Bundle for gateway submission.

Claim EOB Condition Procedure

Patient Layer

ABDM Health Locker Access

Real-time claim status visibility. Patient notifications on fraud flag detection. Consent-based PHI disclosure to insurer.

ABHA ID PHR App ABDM Consent

National Claims Exchange · ABDM Framework · Caladrius CFDF

🏛 National Health Claims Exchange

NHCX Gateway

ABDM-Mandated FHIR Transaction Endpoint · National Health Authority

FHIR R4 Messaging ABHA ID Linking Multi-Payer Exchange HL7 Conformance

🪪

Identity & Cross-Claim Validation

ABHA ID Cross-Insurer Validator

Patient care context API queries across all insurers linked to ABHA ID. Identifies overlapping coverage periods and concurrent multi-payer submissions within the same care episode.

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Caladrius CFDF — Computable Fraud Detection Framework

NHCXFraudDetection · Library v1.2.0 · CQL 1.5 · FHIR R4

Data Layer

FHIR R4 resource modeling: Claim, EOB, InsurancePlan, Organization, Coverage

Logic Layer

CQL Library execution: fraud pattern matching, risk scoring, clinical consistency

Plan Intelligence

FHIR InsurancePlan resource: inclusion/exclusion rules, PM-JAY, CGHS, corporate

Governance Layer

FHIR Library versioning: semantic version control, MO rule intake, telemetry

// NHCXFraudDetection v1.2.0 — Risk Score Engine
define "DuplicateClaimFlag":
  Count([Claim] C where C.created >= Now() - 48 hours) > 3

define "FraudRiskScore":
  (if "UpcodingFlag" then 40 else 0)
  + (if "UnbundlingFlag" then 35 else 0)
  + (if "DuplicateClaimFlag" then 25 else 0)

define "RiskCategory":
  if "FraudRiskScore" >= 60 then 'CRITICAL'
  else if "FraudRiskScore" >= 35 then 'HIGH'
  else 'LOW'

Fraud Risk Score Composition

Upcoding

40 pts

Unbundling

35 pts

Duplicate

25 pts

            ■ LOW <15
            ■ MEDIUM 15–35
            ■ HIGH 35–60
            ■ CRITICAL ≥60
          

            CDS Hook Response Cards

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CARD 1 — Hard Stop: Duplicate Detected

Claim blocked at gateway. ABHA cross-reference match found within active care context. Submission halted pending provider resolution.

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CARD 2 — Warning: Clinical-Billing Mismatch

Billed procedure complexity inconsistent with mapped diagnosis tier. Manual adjudicator review required before settlement.

💡

CARD 3 — Advisory: Coverage Optimization

Documentation gaps identified. Provider guidance issued to improve coverage outcome and reduce denial probability.

          Payer Ecosystem →

Adjudication Hook

CDS Hooks: claim-adjudication

Secondary CDS interception at payer system receipt. Delivers computed risk score, flag justification, and audit trail to payer reviewer.

Payer FHIR Server CDS Cards

Plan Intelligence

FHIR InsurancePlan Validator

Auto-generated CQL rules from plan document define scheme-specific coverage tiers, caps, and inclusion/exclusion criteria for PM-JAY, CGHS, and corporate plans.

PM-JAY CGHS Corporate ECHS

Adjudication Output

Explanation of Benefit (EOB)

Structured EOB resource returned with covered / non-covered service delineation, fraud flag references, and denial reason codes.

FHIR EOB Adjudication

Fraud Typology Coverage

7 Detected Fraud Patterns

Duplicate billing · Upcoding · Unbundling · Phantom billing · Dx–Rx mismatch · Provider frequency anomaly · Cross-insurer overlap

SNOMED CT Match CPT Tier Check Global Freq

Regulatory / Governance

ABDM Framework & NHA Oversight

Immutable audit trail linked to FHIR Library provenance. IRDAI-aligned. Provider anomaly scores surfaced to regulatory bodies via NHCX audit channel.

NHA IRDAI ABDM Audit

Rule Library Governance

Active CQL Libraryv1.2.0

Fraud MO Patterns7 Active

Precision Threshold≥ 90%

Deploy MethodZero-Downtime

Review Cycle30d Post-Deploy

VersioningSemantic (SemVer)

End-to-End Claim Lifecycle — 7-Phase Processing Pipeline

Document
Ingestion

Clinical docs
uploaded

NLP & Coding
Pipeline

SNOMED CT
LOINC · ICD-10

FHIR Bundle
Assembly

ClaimBundle
PS01–PS03

NHCX Gateway
Submission

ABDM endpoint
ABHA ID check

CQL Fraud
Execution

Risk score
7 patterns

CDS Hook
Response

Hard Stop
Warning · Advisory

Payer
Adjudication

EOB issued
Patient notified