Healthcare Financial Services IG Edition 1
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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

CodeSystem: Site Eligibility

Official URL: http://nphies.sa/terminology/CodeSystem/siteEligibility Version: 0.3.0
Active as of 2025-06-23 Computable Name: SiteEligibility

Copyright/Legal: nphies 2020+ (https://nphies.sa)

This code set includes codes indicating the eligibility of the coverage at the identified site.

This Code system is referenced in the content logical definition of the following value sets:

Generated Narrative: CodeSystem siteEligibility

version: 2; Last updated: 2024-08-15 14:37:19+0300

This case-sensitive code system http://nphies.sa/terminology/CodeSystem/siteEligibility defines the following codes:

CodeDisplayDefinitionArabic (ar)
eligible Eligible Code to be used when the patient is eligibile مؤهل
not-active Member's insurance policy is not active When HCP sends an eligibility request for an expired or canceled member’s policy on the eligibility service date. بوليصة التأمين لهذا العضو غير سارية
not-covered Policy does not cover the requested services When HCP sends an eligibility request mentioning a department that offers services out of patient policy coverage. البوليصة لاتغطي الخدمات المطلوبة
out-network Provider outside member Network Facility is outside the member covered policy network. مقدم الخدمة لا ينتمي إلي شبكة التأمين
provider-contract-suspended Provider contract is suspended Provider can be suspended for any reason (regulation, contractual, legal… etc.) التعاقد مع مقدم الخدمة معلق
coverage-suspended Patient coverage is suspended Insurance coverage can be suspended for any reason (regulation, financial, legal, etc.) تغطية هذا المريض معلقة
not-direct billing Patient is not covered on direct billing basis When HCP sends an eligibility request for insured member who is covered on patient reimbursement basis, so even the member has an active policy, but he will pay the medical fees out of his pocket and reimburse the claims. (e.g.: members covered under visit visa insurance policy) المريض غير مغطى على أساس السداد المباشر
limit-exhausted Patient policy/benefit limit is exhausted When member consumed the annual or benefit limit, benefit limit can be indicated from the department in the eligibility request or from the provider type, e.g. request from received from optical shop for a member consumed the optical benefit. الحد الأقصى لهذه الميزة التأمينية للمريض تم استهلاكه