Healthcare Financial Services IG Edition 1
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: Adjudication Reason - TTL Representation

Active as of 2025-06-23

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:CodeSystem ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "adjudication-reason"] ; # 
  fhir:meta [
fhir:versionId [ fhir:v "1" ] ;
fhir:lastUpdated [ fhir:v "2020-11-11T16:23:42.006+02:00"^^xsd:dateTime ]
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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><a name=\"adjudication-reason-en-US\"> </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 &amp; payer</td><td>Submission not compliant with contractual agreement between provider &amp; 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 &quot;الممارسة الكلينيكية&quot;، دون تشخيص إضافي داعم</td></tr></table></div>"^^rdf:XMLLiteral
  ] ; # 
  fhir:url [ fhir:v "http://nphies.sa/terminology/CodeSystem/adjudication-reason"^^xsd:anyURI] ; # 
  fhir:version [ fhir:v "0.3.0"] ; # 
  fhir:name [ fhir:v "AdjudicationReason"] ; # 
  fhir:title [ fhir:v "Adjudication Reason"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:experimental [ fhir:v false] ; # 
  fhir:date [ fhir:v "2025-06-23T22:09:21+03:00"^^xsd:dateTime] ; # 
  fhir:publisher [ fhir:v "HL7 Saudi Arabia"] ; # 
  fhir:contact ( [
fhir:name [ fhir:v "HL7 Saudi Arabia" ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://test-project.org/test-publisher" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "This code set includes a list of the adjudication denial codes."] ; # 
  fhir:jurisdiction ( [
    ( fhir:coding [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "SA" ] ;
fhir:display [ fhir:v "Saudi Arabia" ]     ] )
  ] ) ; # 
  fhir:copyright [ fhir:v "nphies 2020+ (https://nphies.sa)"] ; # 
  fhir:caseSensitive [ fhir:v true] ; # 
  fhir:compositional [ fhir:v false] ; # 
  fhir:versionNeeded [ fhir:v false] ; # 
  fhir:content [ fhir:v "complete"] ; # 
  fhir:concept ( [
fhir:code [ fhir:v "BE-1-2" ] ;
fhir:display [ fhir:v "Service was not performed" ] ;
fhir:definition [ fhir:v "Service was not performed" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "لم يتم تنفيذ الخدمة" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-10" ] ;
fhir:display [ fhir:v "Fraud" ] ;
fhir:definition [ fhir:v "Fraud" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "احتيال" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-5" ] ;
fhir:display [ fhir:v "Medication is not listed in formulary" ] ;
fhir:definition [ fhir:v "Medication is not listed in formulary" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الدواء غير مدرج في لائحة الأدوية المعتمدة" ]     ] )
  ] [
fhir:code [ fhir:v "AD-2-1" ] ;
fhir:display [ fhir:v "Date of birth follows date of service/procedure" ] ;
fhir:definition [ fhir:v "Date of birth follows date of service/procedure" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تاريخ الولادة يعقب تاريخ الخدمة/الإجراء" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-3" ] ;
fhir:display [ fhir:v "Authorization quantity exceeds prescription quantity" ] ;
fhir:definition [ fhir:v "Authorization quantity exceeds prescription quantity" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الكمية المدرجة للموافقة المسبقة تتجاوز الكمية المحددة في الوصفة الطبية" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-1" ] ;
fhir:display [ fhir:v "Co-pay was not collected from member" ] ;
fhir:definition [ fhir:v "Co-pay was not collected from member" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "لم يتم تحصيل المشاركة المالية (التحمل) من العضو" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-7" ] ;
fhir:display [ fhir:v "Service/procedure is inconsistent with encounter type" ] ;
fhir:definition [ fhir:v "Service/procedure is inconsistent with encounter type" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء غير متسقة مع نوع اللقاء الطبي" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-4" ] ;
fhir:display [ fhir:v "Prescription out of date" ] ;
fhir:definition [ fhir:v "Prescription out of date" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "وصفة طبية منتهية الصلاحية" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-1" ] ;
fhir:display [ fhir:v "Vital signs are inadequate or missing" ] ;
fhir:definition [ fhir:v "Vital signs are inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "العلامات الحيوية غير كافية أو مفقودة" ]     ] )
  ] [
fhir:code [ fhir:v "AD-2-6" ] ;
fhir:display [ fhir:v "Service was performed outside authorization validity date" ] ;
fhir:definition [ fhir:v "Service was performed outside authorization validity date" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تم تنفيذ الخدمة خارج تاريخ صلاحية الموافقة المسبقة" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-7" ] ;
fhir:display [ fhir:v "Device is not consistent with the service/procedure" ] ;
fhir:definition [ fhir:v "Device is not consistent with the service/procedure" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الجهاز غير متوافق مع الخدمة/الإجراء" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-10" ] ;
fhir:display [ fhir:v "Device/medications is not approved by the Saudi FDA" ] ;
fhir:definition [ fhir:v "Device/medications is not approved by the Saudi FDA" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الجهاز/الأدوية غير معتمدة من قبل هيئة الغذاء والدواء السعودية" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-5" ] ;
fhir:display [ fhir:v "Diagnosis is inconsistent with patient's age" ] ;
fhir:definition [ fhir:v "Diagnosis is inconsistent with patient's age" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص لا يتوافق مع عمر المريض" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-2" ] ;
fhir:display [ fhir:v "Inappropriate medication duration" ] ;
fhir:definition [ fhir:v "Inappropriate medication duration" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "مدة الدواء غير مناسبة" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-6" ] ;
fhir:display [ fhir:v "Calculation discrepancy" ] ;
fhir:definition [ fhir:v "Calculation discrepancy" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "اختلاف في الحساب" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-6" ] ;
fhir:display [ fhir:v "Milk Products do not meet coverage criteria" ] ;
fhir:definition [ fhir:v "Milk Products do not meet coverage criteria" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "منتجات الألبان لا تلبي معايير التغطية" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-9" ] ;
fhir:display [ fhir:v "Service/procedure/device/medication was included within another service/procedure" ] ;
fhir:definition [ fhir:v "Service/procedure/device/medication was included within another service/procedure" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تم تضمين الخدمة/الإجراء/الجهاز/الدواء ضمن خدمة/إجراء آخر" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-10" ] ;
fhir:display [ fhir:v "Work related injury is not covered" ] ;
fhir:definition [ fhir:v "Work related injury is not covered" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "إصابة العمل غير مشمولة بالتأمين" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-9" ] ;
fhir:display [ fhir:v "Mismatch in member information" ] ;
fhir:definition [ fhir:v "Mismatch in member information" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "عدم تطابق في معلومات العضو" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-8" ] ;
fhir:display [ fhir:v "Clinician registration is invalid or expired" ] ;
fhir:definition [ fhir:v "Clinician registration is invalid or expired" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تسجيل الطبيب غير سار أو منتهي الصلاحية" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-1" ] ;
fhir:display [ fhir:v "Inappropriate medication dose" ] ;
fhir:definition [ fhir:v "Inappropriate medication dose" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "جرعة الدواء غير مناسبة" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-7" ] ;
fhir:display [ fhir:v "Service/procedure is inconsistent with patient's age" ] ;
fhir:definition [ fhir:v "Service/procedure is inconsistent with patient's age" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء لا يتوافق مع عمر المريض" ]     ] )
  ] [
fhir:code [ fhir:v "CV-4-8" ] ;
fhir:display [ fhir:v "Refill too soon" ] ;
fhir:definition [ fhir:v "Refill too soon" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "إعادة وصف الأدوية قبل وقتها المحدد" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-6" ] ;
fhir:display [ fhir:v "Diagnosis is inconsistent with patient's gender" ] ;
fhir:definition [ fhir:v "Diagnosis is inconsistent with patient's gender" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص لا يتوافق مع جنس المريض" ]     ] )
  ] [
fhir:code [ fhir:v "CV-2-1" ] ;
fhir:display [ fhir:v "Patient is not a covered member" ] ;
fhir:definition [ fhir:v "Patient is not a covered member" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "المريض ليس عضوا مغطى" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-3" ] ;
fhir:display [ fhir:v "Chief complaint is inadequate or missing" ] ;
fhir:definition [ fhir:v "Chief complaint is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الشكوى الرئيسية غير كافية أو مفقودة" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-7" ] ;
fhir:display [ fhir:v "Type of diagnosis is inadequate or missing" ] ;
fhir:definition [ fhir:v "Type of diagnosis is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "نوع التشخيص غير كاف أو مفقود" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-6" ] ;
fhir:display [ fhir:v "Pre-existing diagnosis/condition is not covered" ] ;
fhir:definition [ fhir:v "Pre-existing diagnosis/condition is not covered" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "لا يتم تغطية التشخيص/الحالة الموجودة مسبقًا" ]     ] )
  ] [
fhir:code [ fhir:v "AD-2-2" ] ;
fhir:display [ fhir:v "Date of death precedes the date of service/procedure" ] ;
fhir:definition [ fhir:v "Date of death precedes the date of service/procedure" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تاريخ الوفاة يسبق تاريخ الخدمة/الإجراء" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-4" ] ;
fhir:display [ fhir:v "Preauthorization is required and was not obtained" ] ;
fhir:definition [ fhir:v "Preauthorization is required and was not obtained" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمه تتطلب الموافقة المسبقة ولم يتم الحصول عليها" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-10" ] ;
fhir:display [ fhir:v "Patient occupation is inappropriate or missing" ] ;
fhir:definition [ fhir:v "Patient occupation is inappropriate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "مهنة المريض غير مناسبة أو مفقودة" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-5" ] ;
fhir:display [ fhir:v "Claim information is inconsistent with preauthorized services" ] ;
fhir:definition [ fhir:v "Claim information is inconsistent with preauthorized services" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "معلومات المطالبة غير متوافقة مع الخدمات التي تمت الموافقة عليها مسبقًا" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-2" ] ;
fhir:display [ fhir:v "History of present illness is inadequate or missing" ] ;
fhir:definition [ fhir:v "History of present illness is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تاريخ المرض الحالي غير كاف أو مفقود" ]     ] )
  ] [
fhir:code [ fhir:v "CV-3-4" ] ;
fhir:display [ fhir:v "Service/procedure exceeds number of times per policy" ] ;
fhir:definition [ fhir:v "Service/procedure exceeds number of times per policy" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تتجاوز الخدمة/الإجراء عدد المرات المسموح به لكل وثيقة تأمين" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-5" ] ;
fhir:display [ fhir:v "Past medical history is inadequate or missing" ] ;
fhir:definition [ fhir:v "Past medical history is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التاريخ الطبي السابق غير كاف أو مفقود" ]     ] )
  ] [
fhir:code [ fhir:v "AD-2-3" ] ;
fhir:display [ fhir:v "Date of service/procedure is prior to coverage effective date" ] ;
fhir:definition [ fhir:v "Date of service/procedure is prior to coverage effective date" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تاريخ الخدمة/الإجراء يسبق تاريخ سريان التغطية" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-8" ] ;
fhir:display [ fhir:v "Service/procedure is inconsistent with patient's gender" ] ;
fhir:definition [ fhir:v "Service/procedure is inconsistent with patient's gender" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء لا يتوافق مع جنس المريض" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-1" ] ;
fhir:display [ fhir:v "Diagnosis is inconsistent with provider type" ] ;
fhir:definition [ fhir:v "Diagnosis is inconsistent with provider type" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص غير متسق مع نوع مقدم الخدمة" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-2" ] ;
fhir:display [ fhir:v "Provider is not eligible for the service" ] ;
fhir:definition [ fhir:v "Provider is not eligible for the service" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "مقدم الخدمة غير مؤهل للخدمة" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-3" ] ;
fhir:display [ fhir:v "Diagnosis is inconsistent with encounter type" ] ;
fhir:definition [ fhir:v "Diagnosis is inconsistent with encounter type" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص غير متسق مع نوع اللقاء الطبي" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-6" ] ;
fhir:display [ fhir:v "Investigation result is inadequate or missing" ] ;
fhir:definition [ fhir:v "Investigation result is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "نتيجة الفحص غير كافية أو مفقودة" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-4" ] ;
fhir:display [ fhir:v "Service/procedure is not covered" ] ;
fhir:definition [ fhir:v "Service/procedure is not covered" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء غير مغطاة" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-5" ] ;
fhir:display [ fhir:v "Service/procedure does not meet the criteria of urgency criteria" ] ;
fhir:definition [ fhir:v "Service/procedure does not meet the criteria of urgency criteria" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء لا يفي بمعايير الاستعجال" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-4" ] ;
fhir:display [ fhir:v "Physical examination is inadequate or missing" ] ;
fhir:definition [ fhir:v "Physical examination is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الفحص البدني غير كاف أو مفقود" ]     ] )
  ] [
fhir:code [ fhir:v "AD-2-4" ] ;
fhir:display [ fhir:v "Duplicate service/procedure code based on the date" ] ;
fhir:definition [ fhir:v "Duplicate service/procedure code based on the date" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تكرار رمز الخدمة/الإجراء بناءً على التاريخ" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-1" ] ;
fhir:display [ fhir:v "Authorization not required for service/procedure during admitted care" ] ;
fhir:definition [ fhir:v "Authorization not required for service/procedure during admitted care" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الموافقة المسبقة غير مطلوبة للخدمة/الإجراء" ]     ] )
  ] [
fhir:code [ fhir:v "CV-3-2" ] ;
fhir:display [ fhir:v "Service/procedure may be appropriate, but too frequent" ] ;
fhir:definition [ fhir:v "Service/procedure may be appropriate, but too frequent" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "قد تكون الخدمة/الإجراء مناسبًا، ولكنه متكرر جدًا" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-2" ] ;
fhir:display [ fhir:v "Diagnosis is inconsistent with clinician specialty" ] ;
fhir:definition [ fhir:v "Diagnosis is inconsistent with clinician specialty" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص غير متسق مع تخصص الطبيب" ]     ] )
  ] [
fhir:code [ fhir:v "AD-2-5" ] ;
fhir:display [ fhir:v "Time limit for submission has expired" ] ;
fhir:definition [ fhir:v "Time limit for submission has expired" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "لقد انتهت المهلة الزمنية للإرسال" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-5" ] ;
fhir:display [ fhir:v "Service/procedure is inconsistent with provider type" ] ;
fhir:definition [ fhir:v "Service/procedure is inconsistent with provider type" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء غير متسقة مع  نوع مقدم الخدمة" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-4" ] ;
fhir:display [ fhir:v "Diagnosis is inconsistent with service/procedure" ] ;
fhir:definition [ fhir:v "Diagnosis is inconsistent with service/procedure" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص غير متسق مع الخدمة/الإجراء" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-1" ] ;
fhir:display [ fhir:v "Provider is out of beneficiary network" ] ;
fhir:definition [ fhir:v "Provider is out of beneficiary network" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "مقدم الخدمة خارج شبكة التغطية" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-3" ] ;
fhir:display [ fhir:v "Diagnosis is not covered" ] ;
fhir:definition [ fhir:v "Diagnosis is not covered" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "التشخيص غير مغطى" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-2" ] ;
fhir:display [ fhir:v "Use bundled code" ] ;
fhir:definition [ fhir:v "Use bundled code" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "استخدم الكود المجمع" ]     ] )
  ] [
fhir:code [ fhir:v "CV-3-1" ] ;
fhir:display [ fhir:v "Benefit maximum for this time period or occurrence has been reached" ] ;
fhir:definition [ fhir:v "Benefit maximum for this time period or occurrence has been reached" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تم الوصول إلى الحد الأقصى للمنفعة التأمينية لهذه الفترة الزمنية أو الحدث" ]     ] )
  ] [
fhir:code [ fhir:v "CV-3-3" ] ;
fhir:display [ fhir:v "Service/procedure exceeds number of times per life" ] ;
fhir:definition [ fhir:v "Service/procedure exceeds number of times per life" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء يتجاوز عدد المرات المسموح بها خلال الحياة" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-3" ] ;
fhir:display [ fhir:v "Room services and food are included in room and board expenses" ] ;
fhir:definition [ fhir:v "Room services and food are included in room and board expenses" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "يتم تضمين خدمات الغرف والطعام في نفقات الغرفة والطعام" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-3" ] ;
fhir:display [ fhir:v "Submission not compliant with contractual agreement between provider & payer" ] ;
fhir:definition [ fhir:v "Submission not compliant with contractual agreement between provider & payer" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "رفع المطالبات غير متوافق مع الاتفاقية التعاقدية بين مقدم الخدمة والدافع" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-8" ] ;
fhir:display [ fhir:v "Appeal procedures not followed or time limits not met" ] ;
fhir:definition [ fhir:v "Appeal procedures not followed or time limits not met" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "لم يتم اتباع إجراءات الاستئناف أو لم يتم الوفاء بالحدود الزمنية" ]     ] )
  ] [
fhir:code [ fhir:v "AD-1-6" ] ;
fhir:display [ fhir:v "Service/procedure is inconsistent with clinician specialty" ] ;
fhir:definition [ fhir:v "Service/procedure is inconsistent with clinician specialty" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء غير متسقة مع تخصص الطبيب" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-9" ] ;
fhir:display [ fhir:v "Recovery of Payment" ] ;
fhir:definition [ fhir:v "Recovery of Payment" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "استرداد الدفع" ]     ] )
  ] [
fhir:code [ fhir:v "AD-3-4" ] ;
fhir:display [ fhir:v "Incorrect DRG calculated" ] ;
fhir:definition [ fhir:v "Incorrect DRG calculated" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تم حساب الDRG (المجموعة المتعلقة بالمرض) بطريقة خاطئة" ]     ] )
  ] [
fhir:code [ fhir:v "BE-1-7" ] ;
fhir:display [ fhir:v "Incorrect billing regime" ] ;
fhir:definition [ fhir:v "Incorrect billing regime" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "طريقة الفوترة غير صحيحة" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-8" ] ;
fhir:display [ fhir:v "Annual limit/sublimit amount exceeded" ] ;
fhir:definition [ fhir:v "Annual limit/sublimit amount exceeded" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "تم تجاوز الحد/الحد الفرعي السنوي" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-9" ] ;
fhir:display [ fhir:v "Consultation is within 14-day follow up period" ] ;
fhir:definition [ fhir:v "Consultation is within 14-day follow up period" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الاستشارة تكون خلال فترة متابعة مدتها 14 يومًا" ]     ] )
  ] [
fhir:code [ fhir:v "CV-1-7" ] ;
fhir:display [ fhir:v "Pre-existing diagnosis/condition was not disclosed" ] ;
fhir:definition [ fhir:v "Pre-existing diagnosis/condition was not disclosed" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "لم يتم الكشف عن(المصارحة ب) التشخيص/الحالة الموجودة مسبقًا" ]     ] )
  ] [
fhir:code [ fhir:v "CV-3-5" ] ;
fhir:display [ fhir:v "Service/procedure is above Saudi Riyals threshold per policy" ] ;
fhir:definition [ fhir:v "Service/procedure is above Saudi Riyals threshold per policy" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة/الإجراء أعلى من حد الريالات السعودية لكل وثيقة تأمين" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-9" ] ;
fhir:display [ fhir:v "Quantity of service/procedure is inappropriate or missing" ] ;
fhir:definition [ fhir:v "Quantity of service/procedure is inappropriate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "كمية الخدمة/الإجراء غير مناسبة أو مفقودة" ]     ] )
  ] [
fhir:code [ fhir:v "SE-1-8" ] ;
fhir:display [ fhir:v "Treatment plan is inadequate or missing" ] ;
fhir:definition [ fhir:v "Treatment plan is inadequate or missing" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "خطة العلاج غير كافية أو مفقودة" ]     ] )
  ] [
fhir:code [ fhir:v "MN-1-2" ] ;
fhir:display [ fhir:v "Patient is enrolled in hospice/palliative care" ] ;
fhir:definition [ fhir:v "Patient is enrolled in hospice/palliative care" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "المريض مسجل في دار رعاية المسنين/الرعاية التلطيفية" ]     ] )
  ] [
fhir:code [ fhir:v "MN-1-1" ] ;
fhir:display [ fhir:v "Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis" ] ;
fhir:definition [ fhir:v "Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis" ] ;
    ( fhir:designation [
fhir:language [ fhir:v "ar" ] ;
fhir:value [ fhir:v "الخدمة غير مبررة طبياً بناءً على إرشادات \"الممارسة الكلينيكية\"، دون تشخيص إضافي داعم" ]     ] )
  ] ) . #