Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot
Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot
Healthcare Financial Services IG Edition 1 - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Active as of 2025-07-30 |
{
"resourceType" : "CodeSystem",
"id" : "adjudication-reason",
"meta" : {
"versionId" : "1",
"lastUpdated" : "2020-11-11T16:23:42.006+02:00"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem adjudication-reason</b></p><a name=\"adjudication-reason\"> </a><a name=\"hcadjudication-reason\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">version: 1; Last updated: 2020-11-11 16:23:42+0200</p></div><p>This case-sensitive code system <code>http://nphies.sa/terminology/CodeSystem/adjudication-reason</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td><td><b>Arabic (ar)</b></td></tr><tr><td style=\"white-space:nowrap\">BE-1-2<a name=\"adjudication-reason-BE-1-2\"> </a></td><td>Service was not performed</td><td>Service was not performed</td><td>لم يتم تنفيذ الخدمة</td></tr><tr><td style=\"white-space:nowrap\">BE-1-10<a name=\"adjudication-reason-BE-1-10\"> </a></td><td>Fraud</td><td>Fraud</td><td>احتيال</td></tr><tr><td style=\"white-space:nowrap\">CV-4-5<a name=\"adjudication-reason-CV-4-5\"> </a></td><td>Medication is not listed in formulary</td><td>Medication is not listed in formulary</td><td>الدواء غير مدرج في لائحة الأدوية المعتمدة</td></tr><tr><td style=\"white-space:nowrap\">AD-2-1<a name=\"adjudication-reason-AD-2-1\"> </a></td><td>Date of birth follows date of service/procedure</td><td>Date of birth follows date of service/procedure</td><td>تاريخ الولادة يعقب تاريخ الخدمة/الإجراء</td></tr><tr><td style=\"white-space:nowrap\">CV-4-3<a name=\"adjudication-reason-CV-4-3\"> </a></td><td>Authorization quantity exceeds prescription quantity</td><td>Authorization quantity exceeds prescription quantity</td><td>الكمية المدرجة للموافقة المسبقة تتجاوز الكمية المحددة في الوصفة الطبية</td></tr><tr><td style=\"white-space:nowrap\">BE-1-1<a name=\"adjudication-reason-BE-1-1\"> </a></td><td>Co-pay was not collected from member</td><td>Co-pay was not collected from member</td><td>لم يتم تحصيل المشاركة المالية (التحمل) من العضو</td></tr><tr><td style=\"white-space:nowrap\">AD-1-7<a name=\"adjudication-reason-AD-1-7\"> </a></td><td>Service/procedure is inconsistent with encounter type</td><td>Service/procedure is inconsistent with encounter type</td><td>الخدمة/الإجراء غير متسقة مع نوع اللقاء الطبي</td></tr><tr><td style=\"white-space:nowrap\">CV-4-4<a name=\"adjudication-reason-CV-4-4\"> </a></td><td>Prescription out of date</td><td>Prescription out of date</td><td>وصفة طبية منتهية الصلاحية</td></tr><tr><td style=\"white-space:nowrap\">SE-1-1<a name=\"adjudication-reason-SE-1-1\"> </a></td><td>Vital signs are inadequate or missing</td><td>Vital signs are inadequate or missing</td><td>العلامات الحيوية غير كافية أو مفقودة</td></tr><tr><td style=\"white-space:nowrap\">AD-2-6<a name=\"adjudication-reason-AD-2-6\"> </a></td><td>Service was performed outside authorization validity date</td><td>Service was performed outside authorization validity date</td><td>تم تنفيذ الخدمة خارج تاريخ صلاحية الموافقة المسبقة</td></tr><tr><td style=\"white-space:nowrap\">CV-4-7<a name=\"adjudication-reason-CV-4-7\"> </a></td><td>Device is not consistent with the service/procedure</td><td>Device is not consistent with the service/procedure</td><td>الجهاز غير متوافق مع الخدمة/الإجراء</td></tr><tr><td style=\"white-space:nowrap\">CV-4-10<a name=\"adjudication-reason-CV-4-10\"> </a></td><td>Device/medications is not approved by the Saudi FDA</td><td>Device/medications is not approved by the Saudi FDA</td><td>الجهاز/الأدوية غير معتمدة من قبل هيئة الغذاء والدواء السعودية</td></tr><tr><td style=\"white-space:nowrap\">AD-3-5<a name=\"adjudication-reason-AD-3-5\"> </a></td><td>Diagnosis is inconsistent with patient's age</td><td>Diagnosis is inconsistent with patient's age</td><td>التشخيص لا يتوافق مع عمر المريض</td></tr><tr><td style=\"white-space:nowrap\">CV-4-2<a name=\"adjudication-reason-CV-4-2\"> </a></td><td>Inappropriate medication duration</td><td>Inappropriate medication duration</td><td>مدة الدواء غير مناسبة</td></tr><tr><td style=\"white-space:nowrap\">BE-1-6<a name=\"adjudication-reason-BE-1-6\"> </a></td><td>Calculation discrepancy</td><td>Calculation discrepancy</td><td>اختلاف في الحساب</td></tr><tr><td style=\"white-space:nowrap\">CV-4-6<a name=\"adjudication-reason-CV-4-6\"> </a></td><td>Milk Products do not meet coverage criteria</td><td>Milk Products do not meet coverage criteria</td><td>منتجات الألبان لا تلبي معايير التغطية</td></tr><tr><td style=\"white-space:nowrap\">CV-4-9<a name=\"adjudication-reason-CV-4-9\"> </a></td><td>Service/procedure/device/medication was included within another service/procedure</td><td>Service/procedure/device/medication was included within another service/procedure</td><td>تم تضمين الخدمة/الإجراء/الجهاز/الدواء ضمن خدمة/إجراء آخر</td></tr><tr><td style=\"white-space:nowrap\">CV-1-10<a name=\"adjudication-reason-CV-1-10\"> </a></td><td>Work related injury is not covered</td><td>Work related injury is not covered</td><td>إصابة العمل غير مشمولة بالتأمين</td></tr><tr><td style=\"white-space:nowrap\">AD-1-9<a name=\"adjudication-reason-AD-1-9\"> </a></td><td>Mismatch in member information</td><td>Mismatch in member information</td><td>عدم تطابق في معلومات العضو</td></tr><tr><td style=\"white-space:nowrap\">AD-1-8<a name=\"adjudication-reason-AD-1-8\"> </a></td><td>Clinician registration is invalid or expired</td><td>Clinician registration is invalid or expired</td><td>تسجيل الطبيب غير سار أو منتهي الصلاحية</td></tr><tr><td style=\"white-space:nowrap\">CV-4-1<a name=\"adjudication-reason-CV-4-1\"> </a></td><td>Inappropriate medication dose</td><td>Inappropriate medication dose</td><td>جرعة الدواء غير مناسبة</td></tr><tr><td style=\"white-space:nowrap\">AD-3-7<a name=\"adjudication-reason-AD-3-7\"> </a></td><td>Service/procedure is inconsistent with patient's age</td><td>Service/procedure is inconsistent with patient's age</td><td>الخدمة/الإجراء لا يتوافق مع عمر المريض</td></tr><tr><td style=\"white-space:nowrap\">CV-4-8<a name=\"adjudication-reason-CV-4-8\"> </a></td><td>Refill too soon</td><td>Refill too soon</td><td>إعادة وصف الأدوية قبل وقتها المحدد</td></tr><tr><td style=\"white-space:nowrap\">AD-3-6<a name=\"adjudication-reason-AD-3-6\"> </a></td><td>Diagnosis is inconsistent with patient's gender</td><td>Diagnosis is inconsistent with patient's gender</td><td>التشخيص لا يتوافق مع جنس المريض</td></tr><tr><td style=\"white-space:nowrap\">CV-2-1<a name=\"adjudication-reason-CV-2-1\"> </a></td><td>Patient is not a covered member</td><td>Patient is not a covered member</td><td>المريض ليس عضوا مغطى</td></tr><tr><td style=\"white-space:nowrap\">SE-1-3<a name=\"adjudication-reason-SE-1-3\"> </a></td><td>Chief complaint is inadequate or missing</td><td>Chief complaint is inadequate or missing</td><td>الشكوى الرئيسية غير كافية أو مفقودة</td></tr><tr><td style=\"white-space:nowrap\">SE-1-7<a name=\"adjudication-reason-SE-1-7\"> </a></td><td>Type of diagnosis is inadequate or missing</td><td>Type of diagnosis is inadequate or missing</td><td>نوع التشخيص غير كاف أو مفقود</td></tr><tr><td style=\"white-space:nowrap\">CV-1-6<a name=\"adjudication-reason-CV-1-6\"> </a></td><td>Pre-existing diagnosis/condition is not covered</td><td>Pre-existing diagnosis/condition is not covered</td><td>لا يتم تغطية التشخيص/الحالة الموجودة مسبقًا</td></tr><tr><td style=\"white-space:nowrap\">AD-2-2<a name=\"adjudication-reason-AD-2-2\"> </a></td><td>Date of death precedes the date of service/procedure</td><td>Date of death precedes the date of service/procedure</td><td>تاريخ الوفاة يسبق تاريخ الخدمة/الإجراء</td></tr><tr><td style=\"white-space:nowrap\">BE-1-4<a name=\"adjudication-reason-BE-1-4\"> </a></td><td>Preauthorization is required and was not obtained</td><td>Preauthorization is required and was not obtained</td><td>الخدمه تتطلب الموافقة المسبقة ولم يتم الحصول عليها</td></tr><tr><td style=\"white-space:nowrap\">SE-1-10<a name=\"adjudication-reason-SE-1-10\"> </a></td><td>Patient occupation is inappropriate or missing</td><td>Patient occupation is inappropriate or missing</td><td>مهنة المريض غير مناسبة أو مفقودة</td></tr><tr><td style=\"white-space:nowrap\">BE-1-5<a name=\"adjudication-reason-BE-1-5\"> </a></td><td>Claim information is inconsistent with preauthorized services</td><td>Claim information is inconsistent with preauthorized services</td><td>معلومات المطالبة غير متوافقة مع الخدمات التي تمت الموافقة عليها مسبقًا</td></tr><tr><td style=\"white-space:nowrap\">SE-1-2<a name=\"adjudication-reason-SE-1-2\"> </a></td><td>History of present illness is inadequate or missing</td><td>History of present illness is inadequate or missing</td><td>تاريخ المرض الحالي غير كاف أو مفقود</td></tr><tr><td style=\"white-space:nowrap\">CV-3-4<a name=\"adjudication-reason-CV-3-4\"> </a></td><td>Service/procedure exceeds number of times per policy</td><td>Service/procedure exceeds number of times per policy</td><td>تتجاوز الخدمة/الإجراء عدد المرات المسموح به لكل وثيقة تأمين</td></tr><tr><td style=\"white-space:nowrap\">SE-1-5<a name=\"adjudication-reason-SE-1-5\"> </a></td><td>Past medical history is inadequate or missing</td><td>Past medical history is inadequate or missing</td><td>التاريخ الطبي السابق غير كاف أو مفقود</td></tr><tr><td style=\"white-space:nowrap\">AD-2-3<a name=\"adjudication-reason-AD-2-3\"> </a></td><td>Date of service/procedure is prior to coverage effective date</td><td>Date of service/procedure is prior to coverage effective date</td><td>تاريخ الخدمة/الإجراء يسبق تاريخ سريان التغطية</td></tr><tr><td style=\"white-space:nowrap\">AD-3-8<a name=\"adjudication-reason-AD-3-8\"> </a></td><td>Service/procedure is inconsistent with patient's gender</td><td>Service/procedure is inconsistent with patient's gender</td><td>الخدمة/الإجراء لا يتوافق مع جنس المريض</td></tr><tr><td style=\"white-space:nowrap\">AD-1-1<a name=\"adjudication-reason-AD-1-1\"> </a></td><td>Diagnosis is inconsistent with provider type</td><td>Diagnosis is inconsistent with provider type</td><td>التشخيص غير متسق مع نوع مقدم الخدمة</td></tr><tr><td style=\"white-space:nowrap\">CV-1-2<a name=\"adjudication-reason-CV-1-2\"> </a></td><td>Provider is not eligible for the service</td><td>Provider is not eligible for the service</td><td>مقدم الخدمة غير مؤهل للخدمة</td></tr><tr><td style=\"white-space:nowrap\">AD-1-3<a name=\"adjudication-reason-AD-1-3\"> </a></td><td>Diagnosis is inconsistent with encounter type</td><td>Diagnosis is inconsistent with encounter type</td><td>التشخيص غير متسق مع نوع اللقاء الطبي</td></tr><tr><td style=\"white-space:nowrap\">SE-1-6<a name=\"adjudication-reason-SE-1-6\"> </a></td><td>Investigation result is inadequate or missing</td><td>Investigation result is inadequate or missing</td><td>نتيجة الفحص غير كافية أو مفقودة</td></tr><tr><td style=\"white-space:nowrap\">CV-1-4<a name=\"adjudication-reason-CV-1-4\"> </a></td><td>Service/procedure is not covered</td><td>Service/procedure is not covered</td><td>الخدمة/الإجراء غير مغطاة</td></tr><tr><td style=\"white-space:nowrap\">CV-1-5<a name=\"adjudication-reason-CV-1-5\"> </a></td><td>Service/procedure does not meet the criteria of urgency criteria</td><td>Service/procedure does not meet the criteria of urgency criteria</td><td>الخدمة/الإجراء لا يفي بمعايير الاستعجال</td></tr><tr><td style=\"white-space:nowrap\">SE-1-4<a name=\"adjudication-reason-SE-1-4\"> </a></td><td>Physical examination is inadequate or missing</td><td>Physical examination is inadequate or missing</td><td>الفحص البدني غير كاف أو مفقود</td></tr><tr><td style=\"white-space:nowrap\">AD-2-4<a name=\"adjudication-reason-AD-2-4\"> </a></td><td>Duplicate service/procedure code based on the date</td><td>Duplicate service/procedure code based on the date</td><td>تكرار رمز الخدمة/الإجراء بناءً على التاريخ</td></tr><tr><td style=\"white-space:nowrap\">AD-3-1<a name=\"adjudication-reason-AD-3-1\"> </a></td><td>Authorization not required for service/procedure during admitted care</td><td>Authorization not required for service/procedure during admitted care</td><td>الموافقة المسبقة غير مطلوبة للخدمة/الإجراء</td></tr><tr><td style=\"white-space:nowrap\">CV-3-2<a name=\"adjudication-reason-CV-3-2\"> </a></td><td>Service/procedure may be appropriate, but too frequent</td><td>Service/procedure may be appropriate, but too frequent</td><td>قد تكون الخدمة/الإجراء مناسبًا، ولكنه متكرر جدًا</td></tr><tr><td style=\"white-space:nowrap\">AD-1-2<a name=\"adjudication-reason-AD-1-2\"> </a></td><td>Diagnosis is inconsistent with clinician specialty</td><td>Diagnosis is inconsistent with clinician specialty</td><td>التشخيص غير متسق مع تخصص الطبيب</td></tr><tr><td style=\"white-space:nowrap\">AD-2-5<a name=\"adjudication-reason-AD-2-5\"> </a></td><td>Time limit for submission has expired</td><td>Time limit for submission has expired</td><td>لقد انتهت المهلة الزمنية للإرسال</td></tr><tr><td style=\"white-space:nowrap\">AD-1-5<a name=\"adjudication-reason-AD-1-5\"> </a></td><td>Service/procedure is inconsistent with provider type</td><td>Service/procedure is inconsistent with provider type</td><td>الخدمة/الإجراء غير متسقة مع نوع مقدم الخدمة</td></tr><tr><td style=\"white-space:nowrap\">AD-1-4<a name=\"adjudication-reason-AD-1-4\"> </a></td><td>Diagnosis is inconsistent with service/procedure</td><td>Diagnosis is inconsistent with service/procedure</td><td>التشخيص غير متسق مع الخدمة/الإجراء</td></tr><tr><td style=\"white-space:nowrap\">CV-1-1<a name=\"adjudication-reason-CV-1-1\"> </a></td><td>Provider is out of beneficiary network</td><td>Provider is out of beneficiary network</td><td>مقدم الخدمة خارج شبكة التغطية</td></tr><tr><td style=\"white-space:nowrap\">CV-1-3<a name=\"adjudication-reason-CV-1-3\"> </a></td><td>Diagnosis is not covered</td><td>Diagnosis is not covered</td><td>التشخيص غير مغطى</td></tr><tr><td style=\"white-space:nowrap\">AD-3-2<a name=\"adjudication-reason-AD-3-2\"> </a></td><td>Use bundled code</td><td>Use bundled code</td><td>استخدم الكود المجمع</td></tr><tr><td style=\"white-space:nowrap\">CV-3-1<a name=\"adjudication-reason-CV-3-1\"> </a></td><td>Benefit maximum for this time period or occurrence has been reached</td><td>Benefit maximum for this time period or occurrence has been reached</td><td>تم الوصول إلى الحد الأقصى للمنفعة التأمينية لهذه الفترة الزمنية أو الحدث</td></tr><tr><td style=\"white-space:nowrap\">CV-3-3<a name=\"adjudication-reason-CV-3-3\"> </a></td><td>Service/procedure exceeds number of times per life</td><td>Service/procedure exceeds number of times per life</td><td>الخدمة/الإجراء يتجاوز عدد المرات المسموح بها خلال الحياة</td></tr><tr><td style=\"white-space:nowrap\">AD-3-3<a name=\"adjudication-reason-AD-3-3\"> </a></td><td>Room services and food are included in room and board expenses</td><td>Room services and food are included in room and board expenses</td><td>يتم تضمين خدمات الغرف والطعام في نفقات الغرفة والطعام</td></tr><tr><td style=\"white-space:nowrap\">BE-1-3<a name=\"adjudication-reason-BE-1-3\"> </a></td><td>Submission not compliant with contractual agreement between provider & payer</td><td>Submission not compliant with contractual agreement between provider & payer</td><td>رفع المطالبات غير متوافق مع الاتفاقية التعاقدية بين مقدم الخدمة والدافع</td></tr><tr><td style=\"white-space:nowrap\">BE-1-8<a name=\"adjudication-reason-BE-1-8\"> </a></td><td>Appeal procedures not followed or time limits not met</td><td>Appeal procedures not followed or time limits not met</td><td>لم يتم اتباع إجراءات الاستئناف أو لم يتم الوفاء بالحدود الزمنية</td></tr><tr><td style=\"white-space:nowrap\">AD-1-6<a name=\"adjudication-reason-AD-1-6\"> </a></td><td>Service/procedure is inconsistent with clinician specialty</td><td>Service/procedure is inconsistent with clinician specialty</td><td>الخدمة/الإجراء غير متسقة مع تخصص الطبيب</td></tr><tr><td style=\"white-space:nowrap\">BE-1-9<a name=\"adjudication-reason-BE-1-9\"> </a></td><td>Recovery of Payment</td><td>Recovery of Payment</td><td>استرداد الدفع</td></tr><tr><td style=\"white-space:nowrap\">AD-3-4<a name=\"adjudication-reason-AD-3-4\"> </a></td><td>Incorrect DRG calculated</td><td>Incorrect DRG calculated</td><td>تم حساب الDRG (المجموعة المتعلقة بالمرض) بطريقة خاطئة</td></tr><tr><td style=\"white-space:nowrap\">BE-1-7<a name=\"adjudication-reason-BE-1-7\"> </a></td><td>Incorrect billing regime</td><td>Incorrect billing regime</td><td>طريقة الفوترة غير صحيحة</td></tr><tr><td style=\"white-space:nowrap\">CV-1-8<a name=\"adjudication-reason-CV-1-8\"> </a></td><td>Annual limit/sublimit amount exceeded</td><td>Annual limit/sublimit amount exceeded</td><td>تم تجاوز الحد/الحد الفرعي السنوي</td></tr><tr><td style=\"white-space:nowrap\">CV-1-9<a name=\"adjudication-reason-CV-1-9\"> </a></td><td>Consultation is within 14-day follow up period</td><td>Consultation is within 14-day follow up period</td><td>الاستشارة تكون خلال فترة متابعة مدتها 14 يومًا</td></tr><tr><td style=\"white-space:nowrap\">CV-1-7<a name=\"adjudication-reason-CV-1-7\"> </a></td><td>Pre-existing diagnosis/condition was not disclosed</td><td>Pre-existing diagnosis/condition was not disclosed</td><td>لم يتم الكشف عن(المصارحة ب) التشخيص/الحالة الموجودة مسبقًا</td></tr><tr><td style=\"white-space:nowrap\">CV-3-5<a name=\"adjudication-reason-CV-3-5\"> </a></td><td>Service/procedure is above Saudi Riyals threshold per policy</td><td>Service/procedure is above Saudi Riyals threshold per policy</td><td>الخدمة/الإجراء أعلى من حد الريالات السعودية لكل وثيقة تأمين</td></tr><tr><td style=\"white-space:nowrap\">SE-1-9<a name=\"adjudication-reason-SE-1-9\"> </a></td><td>Quantity of service/procedure is inappropriate or missing</td><td>Quantity of service/procedure is inappropriate or missing</td><td>كمية الخدمة/الإجراء غير مناسبة أو مفقودة</td></tr><tr><td style=\"white-space:nowrap\">SE-1-8<a name=\"adjudication-reason-SE-1-8\"> </a></td><td>Treatment plan is inadequate or missing</td><td>Treatment plan is inadequate or missing</td><td>خطة العلاج غير كافية أو مفقودة</td></tr><tr><td style=\"white-space:nowrap\">MN-1-2<a name=\"adjudication-reason-MN-1-2\"> </a></td><td>Patient is enrolled in hospice/palliative care</td><td>Patient is enrolled in hospice/palliative care</td><td>المريض مسجل في دار رعاية المسنين/الرعاية التلطيفية</td></tr><tr><td style=\"white-space:nowrap\">MN-1-1<a name=\"adjudication-reason-MN-1-1\"> </a></td><td>Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis</td><td>Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis</td><td>الخدمة غير مبررة طبياً بناءً على إرشادات "الممارسة الكلينيكية"، دون تشخيص إضافي داعم</td></tr></table></div>"
},
"url" : "http://nphies.sa/terminology/CodeSystem/adjudication-reason",
"version" : "0.3.0",
"name" : "AdjudicationReason",
"title" : "Adjudication Reason",
"status" : "active",
"experimental" : false,
"date" : "2025-07-30T12:41:32+03:00",
"publisher" : "HL7 Saudi Arabia",
"contact" : [
{
"name" : "HL7 Saudi Arabia",
"telecom" : [
{
"system" : "url",
"value" : "http://test-project.org/test-publisher"
}
]
}
],
"description" : "This code set includes a list of the adjudication denial codes.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "SA",
"display" : "Saudi Arabia"
}
]
}
],
"copyright" : "nphies 2020+ (https://nphies.sa)",
"caseSensitive" : true,
"compositional" : false,
"versionNeeded" : false,
"content" : "complete",
"concept" : [
{
"code" : "BE-1-2",
"display" : "Service was not performed",
"definition" : "Service was not performed",
"designation" : [
{
"language" : "ar",
"value" : "لم يتم تنفيذ الخدمة"
}
]
},
{
"code" : "BE-1-10",
"display" : "Fraud",
"definition" : "Fraud",
"designation" : [
{
"language" : "ar",
"value" : "احتيال"
}
]
},
{
"code" : "CV-4-5",
"display" : "Medication is not listed in formulary",
"definition" : "Medication is not listed in formulary",
"designation" : [
{
"language" : "ar",
"value" : "الدواء غير مدرج في لائحة الأدوية المعتمدة"
}
]
},
{
"code" : "AD-2-1",
"display" : "Date of birth follows date of service/procedure",
"definition" : "Date of birth follows date of service/procedure",
"designation" : [
{
"language" : "ar",
"value" : "تاريخ الولادة يعقب تاريخ الخدمة/الإجراء"
}
]
},
{
"code" : "CV-4-3",
"display" : "Authorization quantity exceeds prescription quantity",
"definition" : "Authorization quantity exceeds prescription quantity",
"designation" : [
{
"language" : "ar",
"value" : "الكمية المدرجة للموافقة المسبقة تتجاوز الكمية المحددة في الوصفة الطبية"
}
]
},
{
"code" : "BE-1-1",
"display" : "Co-pay was not collected from member",
"definition" : "Co-pay was not collected from member",
"designation" : [
{
"language" : "ar",
"value" : "لم يتم تحصيل المشاركة المالية (التحمل) من العضو"
}
]
},
{
"code" : "AD-1-7",
"display" : "Service/procedure is inconsistent with encounter type",
"definition" : "Service/procedure is inconsistent with encounter type",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء غير متسقة مع نوع اللقاء الطبي"
}
]
},
{
"code" : "CV-4-4",
"display" : "Prescription out of date",
"definition" : "Prescription out of date",
"designation" : [
{
"language" : "ar",
"value" : "وصفة طبية منتهية الصلاحية"
}
]
},
{
"code" : "SE-1-1",
"display" : "Vital signs are inadequate or missing",
"definition" : "Vital signs are inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "العلامات الحيوية غير كافية أو مفقودة"
}
]
},
{
"code" : "AD-2-6",
"display" : "Service was performed outside authorization validity date",
"definition" : "Service was performed outside authorization validity date",
"designation" : [
{
"language" : "ar",
"value" : "تم تنفيذ الخدمة خارج تاريخ صلاحية الموافقة المسبقة"
}
]
},
{
"code" : "CV-4-7",
"display" : "Device is not consistent with the service/procedure",
"definition" : "Device is not consistent with the service/procedure",
"designation" : [
{
"language" : "ar",
"value" : "الجهاز غير متوافق مع الخدمة/الإجراء"
}
]
},
{
"code" : "CV-4-10",
"display" : "Device/medications is not approved by the Saudi FDA",
"definition" : "Device/medications is not approved by the Saudi FDA",
"designation" : [
{
"language" : "ar",
"value" : "الجهاز/الأدوية غير معتمدة من قبل هيئة الغذاء والدواء السعودية"
}
]
},
{
"code" : "AD-3-5",
"display" : "Diagnosis is inconsistent with patient's age",
"definition" : "Diagnosis is inconsistent with patient's age",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص لا يتوافق مع عمر المريض"
}
]
},
{
"code" : "CV-4-2",
"display" : "Inappropriate medication duration",
"definition" : "Inappropriate medication duration",
"designation" : [
{
"language" : "ar",
"value" : "مدة الدواء غير مناسبة"
}
]
},
{
"code" : "BE-1-6",
"display" : "Calculation discrepancy",
"definition" : "Calculation discrepancy",
"designation" : [
{
"language" : "ar",
"value" : "اختلاف في الحساب"
}
]
},
{
"code" : "CV-4-6",
"display" : "Milk Products do not meet coverage criteria",
"definition" : "Milk Products do not meet coverage criteria",
"designation" : [
{
"language" : "ar",
"value" : "منتجات الألبان لا تلبي معايير التغطية"
}
]
},
{
"code" : "CV-4-9",
"display" : "Service/procedure/device/medication was included within another service/procedure",
"definition" : "Service/procedure/device/medication was included within another service/procedure",
"designation" : [
{
"language" : "ar",
"value" : "تم تضمين الخدمة/الإجراء/الجهاز/الدواء ضمن خدمة/إجراء آخر"
}
]
},
{
"code" : "CV-1-10",
"display" : "Work related injury is not covered",
"definition" : "Work related injury is not covered",
"designation" : [
{
"language" : "ar",
"value" : "إصابة العمل غير مشمولة بالتأمين"
}
]
},
{
"code" : "AD-1-9",
"display" : "Mismatch in member information",
"definition" : "Mismatch in member information",
"designation" : [
{
"language" : "ar",
"value" : "عدم تطابق في معلومات العضو"
}
]
},
{
"code" : "AD-1-8",
"display" : "Clinician registration is invalid or expired",
"definition" : "Clinician registration is invalid or expired",
"designation" : [
{
"language" : "ar",
"value" : "تسجيل الطبيب غير سار أو منتهي الصلاحية"
}
]
},
{
"code" : "CV-4-1",
"display" : "Inappropriate medication dose",
"definition" : "Inappropriate medication dose",
"designation" : [
{
"language" : "ar",
"value" : "جرعة الدواء غير مناسبة"
}
]
},
{
"code" : "AD-3-7",
"display" : "Service/procedure is inconsistent with patient's age",
"definition" : "Service/procedure is inconsistent with patient's age",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء لا يتوافق مع عمر المريض"
}
]
},
{
"code" : "CV-4-8",
"display" : "Refill too soon",
"definition" : "Refill too soon",
"designation" : [
{
"language" : "ar",
"value" : "إعادة وصف الأدوية قبل وقتها المحدد"
}
]
},
{
"code" : "AD-3-6",
"display" : "Diagnosis is inconsistent with patient's gender",
"definition" : "Diagnosis is inconsistent with patient's gender",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص لا يتوافق مع جنس المريض"
}
]
},
{
"code" : "CV-2-1",
"display" : "Patient is not a covered member",
"definition" : "Patient is not a covered member",
"designation" : [
{
"language" : "ar",
"value" : "المريض ليس عضوا مغطى"
}
]
},
{
"code" : "SE-1-3",
"display" : "Chief complaint is inadequate or missing",
"definition" : "Chief complaint is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "الشكوى الرئيسية غير كافية أو مفقودة"
}
]
},
{
"code" : "SE-1-7",
"display" : "Type of diagnosis is inadequate or missing",
"definition" : "Type of diagnosis is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "نوع التشخيص غير كاف أو مفقود"
}
]
},
{
"code" : "CV-1-6",
"display" : "Pre-existing diagnosis/condition is not covered",
"definition" : "Pre-existing diagnosis/condition is not covered",
"designation" : [
{
"language" : "ar",
"value" : "لا يتم تغطية التشخيص/الحالة الموجودة مسبقًا"
}
]
},
{
"code" : "AD-2-2",
"display" : "Date of death precedes the date of service/procedure",
"definition" : "Date of death precedes the date of service/procedure",
"designation" : [
{
"language" : "ar",
"value" : "تاريخ الوفاة يسبق تاريخ الخدمة/الإجراء"
}
]
},
{
"code" : "BE-1-4",
"display" : "Preauthorization is required and was not obtained",
"definition" : "Preauthorization is required and was not obtained",
"designation" : [
{
"language" : "ar",
"value" : "الخدمه تتطلب الموافقة المسبقة ولم يتم الحصول عليها"
}
]
},
{
"code" : "SE-1-10",
"display" : "Patient occupation is inappropriate or missing",
"definition" : "Patient occupation is inappropriate or missing",
"designation" : [
{
"language" : "ar",
"value" : "مهنة المريض غير مناسبة أو مفقودة"
}
]
},
{
"code" : "BE-1-5",
"display" : "Claim information is inconsistent with preauthorized services",
"definition" : "Claim information is inconsistent with preauthorized services",
"designation" : [
{
"language" : "ar",
"value" : "معلومات المطالبة غير متوافقة مع الخدمات التي تمت الموافقة عليها مسبقًا"
}
]
},
{
"code" : "SE-1-2",
"display" : "History of present illness is inadequate or missing",
"definition" : "History of present illness is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "تاريخ المرض الحالي غير كاف أو مفقود"
}
]
},
{
"code" : "CV-3-4",
"display" : "Service/procedure exceeds number of times per policy",
"definition" : "Service/procedure exceeds number of times per policy",
"designation" : [
{
"language" : "ar",
"value" : "تتجاوز الخدمة/الإجراء عدد المرات المسموح به لكل وثيقة تأمين"
}
]
},
{
"code" : "SE-1-5",
"display" : "Past medical history is inadequate or missing",
"definition" : "Past medical history is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "التاريخ الطبي السابق غير كاف أو مفقود"
}
]
},
{
"code" : "AD-2-3",
"display" : "Date of service/procedure is prior to coverage effective date",
"definition" : "Date of service/procedure is prior to coverage effective date",
"designation" : [
{
"language" : "ar",
"value" : "تاريخ الخدمة/الإجراء يسبق تاريخ سريان التغطية"
}
]
},
{
"code" : "AD-3-8",
"display" : "Service/procedure is inconsistent with patient's gender",
"definition" : "Service/procedure is inconsistent with patient's gender",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء لا يتوافق مع جنس المريض"
}
]
},
{
"code" : "AD-1-1",
"display" : "Diagnosis is inconsistent with provider type",
"definition" : "Diagnosis is inconsistent with provider type",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص غير متسق مع نوع مقدم الخدمة"
}
]
},
{
"code" : "CV-1-2",
"display" : "Provider is not eligible for the service",
"definition" : "Provider is not eligible for the service",
"designation" : [
{
"language" : "ar",
"value" : "مقدم الخدمة غير مؤهل للخدمة"
}
]
},
{
"code" : "AD-1-3",
"display" : "Diagnosis is inconsistent with encounter type",
"definition" : "Diagnosis is inconsistent with encounter type",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص غير متسق مع نوع اللقاء الطبي"
}
]
},
{
"code" : "SE-1-6",
"display" : "Investigation result is inadequate or missing",
"definition" : "Investigation result is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "نتيجة الفحص غير كافية أو مفقودة"
}
]
},
{
"code" : "CV-1-4",
"display" : "Service/procedure is not covered",
"definition" : "Service/procedure is not covered",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء غير مغطاة"
}
]
},
{
"code" : "CV-1-5",
"display" : "Service/procedure does not meet the criteria of urgency criteria",
"definition" : "Service/procedure does not meet the criteria of urgency criteria",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء لا يفي بمعايير الاستعجال"
}
]
},
{
"code" : "SE-1-4",
"display" : "Physical examination is inadequate or missing",
"definition" : "Physical examination is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "الفحص البدني غير كاف أو مفقود"
}
]
},
{
"code" : "AD-2-4",
"display" : "Duplicate service/procedure code based on the date",
"definition" : "Duplicate service/procedure code based on the date",
"designation" : [
{
"language" : "ar",
"value" : "تكرار رمز الخدمة/الإجراء بناءً على التاريخ"
}
]
},
{
"code" : "AD-3-1",
"display" : "Authorization not required for service/procedure during admitted care",
"definition" : "Authorization not required for service/procedure during admitted care",
"designation" : [
{
"language" : "ar",
"value" : "الموافقة المسبقة غير مطلوبة للخدمة/الإجراء"
}
]
},
{
"code" : "CV-3-2",
"display" : "Service/procedure may be appropriate, but too frequent",
"definition" : "Service/procedure may be appropriate, but too frequent",
"designation" : [
{
"language" : "ar",
"value" : "قد تكون الخدمة/الإجراء مناسبًا، ولكنه متكرر جدًا"
}
]
},
{
"code" : "AD-1-2",
"display" : "Diagnosis is inconsistent with clinician specialty",
"definition" : "Diagnosis is inconsistent with clinician specialty",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص غير متسق مع تخصص الطبيب"
}
]
},
{
"code" : "AD-2-5",
"display" : "Time limit for submission has expired",
"definition" : "Time limit for submission has expired",
"designation" : [
{
"language" : "ar",
"value" : "لقد انتهت المهلة الزمنية للإرسال"
}
]
},
{
"code" : "AD-1-5",
"display" : "Service/procedure is inconsistent with provider type",
"definition" : "Service/procedure is inconsistent with provider type",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء غير متسقة مع نوع مقدم الخدمة"
}
]
},
{
"code" : "AD-1-4",
"display" : "Diagnosis is inconsistent with service/procedure",
"definition" : "Diagnosis is inconsistent with service/procedure",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص غير متسق مع الخدمة/الإجراء"
}
]
},
{
"code" : "CV-1-1",
"display" : "Provider is out of beneficiary network",
"definition" : "Provider is out of beneficiary network",
"designation" : [
{
"language" : "ar",
"value" : "مقدم الخدمة خارج شبكة التغطية"
}
]
},
{
"code" : "CV-1-3",
"display" : "Diagnosis is not covered",
"definition" : "Diagnosis is not covered",
"designation" : [
{
"language" : "ar",
"value" : "التشخيص غير مغطى"
}
]
},
{
"code" : "AD-3-2",
"display" : "Use bundled code",
"definition" : "Use bundled code",
"designation" : [
{
"language" : "ar",
"value" : "استخدم الكود المجمع"
}
]
},
{
"code" : "CV-3-1",
"display" : "Benefit maximum for this time period or occurrence has been reached",
"definition" : "Benefit maximum for this time period or occurrence has been reached",
"designation" : [
{
"language" : "ar",
"value" : "تم الوصول إلى الحد الأقصى للمنفعة التأمينية لهذه الفترة الزمنية أو الحدث"
}
]
},
{
"code" : "CV-3-3",
"display" : "Service/procedure exceeds number of times per life",
"definition" : "Service/procedure exceeds number of times per life",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء يتجاوز عدد المرات المسموح بها خلال الحياة"
}
]
},
{
"code" : "AD-3-3",
"display" : "Room services and food are included in room and board expenses",
"definition" : "Room services and food are included in room and board expenses",
"designation" : [
{
"language" : "ar",
"value" : "يتم تضمين خدمات الغرف والطعام في نفقات الغرفة والطعام"
}
]
},
{
"code" : "BE-1-3",
"display" : "Submission not compliant with contractual agreement between provider & payer",
"definition" : "Submission not compliant with contractual agreement between provider & payer",
"designation" : [
{
"language" : "ar",
"value" : "رفع المطالبات غير متوافق مع الاتفاقية التعاقدية بين مقدم الخدمة والدافع"
}
]
},
{
"code" : "BE-1-8",
"display" : "Appeal procedures not followed or time limits not met",
"definition" : "Appeal procedures not followed or time limits not met",
"designation" : [
{
"language" : "ar",
"value" : "لم يتم اتباع إجراءات الاستئناف أو لم يتم الوفاء بالحدود الزمنية"
}
]
},
{
"code" : "AD-1-6",
"display" : "Service/procedure is inconsistent with clinician specialty",
"definition" : "Service/procedure is inconsistent with clinician specialty",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء غير متسقة مع تخصص الطبيب"
}
]
},
{
"code" : "BE-1-9",
"display" : "Recovery of Payment",
"definition" : "Recovery of Payment",
"designation" : [
{
"language" : "ar",
"value" : "استرداد الدفع"
}
]
},
{
"code" : "AD-3-4",
"display" : "Incorrect DRG calculated",
"definition" : "Incorrect DRG calculated",
"designation" : [
{
"language" : "ar",
"value" : "تم حساب الDRG (المجموعة المتعلقة بالمرض) بطريقة خاطئة"
}
]
},
{
"code" : "BE-1-7",
"display" : "Incorrect billing regime",
"definition" : "Incorrect billing regime",
"designation" : [
{
"language" : "ar",
"value" : "طريقة الفوترة غير صحيحة"
}
]
},
{
"code" : "CV-1-8",
"display" : "Annual limit/sublimit amount exceeded",
"definition" : "Annual limit/sublimit amount exceeded",
"designation" : [
{
"language" : "ar",
"value" : "تم تجاوز الحد/الحد الفرعي السنوي"
}
]
},
{
"code" : "CV-1-9",
"display" : "Consultation is within 14-day follow up period",
"definition" : "Consultation is within 14-day follow up period",
"designation" : [
{
"language" : "ar",
"value" : "الاستشارة تكون خلال فترة متابعة مدتها 14 يومًا"
}
]
},
{
"code" : "CV-1-7",
"display" : "Pre-existing diagnosis/condition was not disclosed",
"definition" : "Pre-existing diagnosis/condition was not disclosed",
"designation" : [
{
"language" : "ar",
"value" : "لم يتم الكشف عن(المصارحة ب) التشخيص/الحالة الموجودة مسبقًا"
}
]
},
{
"code" : "CV-3-5",
"display" : "Service/procedure is above Saudi Riyals threshold per policy",
"definition" : "Service/procedure is above Saudi Riyals threshold per policy",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة/الإجراء أعلى من حد الريالات السعودية لكل وثيقة تأمين"
}
]
},
{
"code" : "SE-1-9",
"display" : "Quantity of service/procedure is inappropriate or missing",
"definition" : "Quantity of service/procedure is inappropriate or missing",
"designation" : [
{
"language" : "ar",
"value" : "كمية الخدمة/الإجراء غير مناسبة أو مفقودة"
}
]
},
{
"code" : "SE-1-8",
"display" : "Treatment plan is inadequate or missing",
"definition" : "Treatment plan is inadequate or missing",
"designation" : [
{
"language" : "ar",
"value" : "خطة العلاج غير كافية أو مفقودة"
}
]
},
{
"code" : "MN-1-2",
"display" : "Patient is enrolled in hospice/palliative care",
"definition" : "Patient is enrolled in hospice/palliative care",
"designation" : [
{
"language" : "ar",
"value" : "المريض مسجل في دار رعاية المسنين/الرعاية التلطيفية"
}
]
},
{
"code" : "MN-1-1",
"display" : "Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis",
"definition" : "Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis",
"designation" : [
{
"language" : "ar",
"value" : "الخدمة غير مبررة طبياً بناءً على إرشادات \"الممارسة الكلينيكية\"، دون تشخيص إضافي داعم"
}
]
}
]
}