Healthcare Financial Services IG Edition 1
0.3.0 - ci-build
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
: Site Eligibility - XML Representation
| Active as of 2025-06-23 |
<CodeSystem xmlns="http://hl7.org/fhir">
<id value="siteEligibility"/>
<meta>
<versionId value="2"/>
<lastUpdated value="2024-08-15T14:37:19.259+03:00"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem siteEligibility</b></p><a name="siteEligibility"> </a><a name="hcsiteEligibility"> </a><a name="siteEligibility-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: 2; Last updated: 2024-08-15 14:37:19+0300</p></div><p>This case-sensitive code system <code>http://nphies.sa/terminology/CodeSystem/siteEligibility</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">eligible<a name="siteEligibility-eligible"> </a></td><td>Eligible</td><td>Code to be used when the patient is eligibile</td><td>مؤهل</td></tr><tr><td style="white-space:nowrap">not-active<a name="siteEligibility-not-active"> </a></td><td>Member's insurance policy is not active</td><td>When HCP sends an eligibility request for an expired or canceled member’s policy on the eligibility service date.</td><td>بوليصة التأمين لهذا العضو غير سارية</td></tr><tr><td style="white-space:nowrap">not-covered<a name="siteEligibility-not-covered"> </a></td><td>Policy does not cover the requested services</td><td>When HCP sends an eligibility request mentioning a department that offers services out of patient policy coverage.</td><td>البوليصة لاتغطي الخدمات المطلوبة</td></tr><tr><td style="white-space:nowrap">out-network<a name="siteEligibility-out-network"> </a></td><td>Provider outside member Network</td><td>Facility is outside the member covered policy network.</td><td>مقدم الخدمة لا ينتمي إلي شبكة التأمين</td></tr><tr><td style="white-space:nowrap">provider-contract-suspended<a name="siteEligibility-provider-contract-suspended"> </a></td><td>Provider contract is suspended</td><td>Provider can be suspended for any reason (regulation, contractual, legal… etc.)</td><td>التعاقد مع مقدم الخدمة معلق</td></tr><tr><td style="white-space:nowrap">coverage-suspended<a name="siteEligibility-coverage-suspended"> </a></td><td>Patient coverage is suspended</td><td>Insurance coverage can be suspended for any reason (regulation, financial, legal, etc.)</td><td>تغطية هذا المريض معلقة</td></tr><tr><td style="white-space:nowrap">not-direct billing<a name="siteEligibility-not-directbilling"> </a></td><td>Patient is not covered on direct billing basis</td><td>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)</td><td>المريض غير مغطى على أساس السداد المباشر</td></tr><tr><td style="white-space:nowrap">limit-exhausted<a name="siteEligibility-limit-exhausted"> </a></td><td>Patient policy/benefit limit is exhausted</td><td>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.</td><td>الحد الأقصى لهذه الميزة التأمينية للمريض تم استهلاكه</td></tr></table></div>
</text>
<url value="http://nphies.sa/terminology/CodeSystem/siteEligibility"/>
<version value="0.3.0"/>
<name value="SiteEligibility"/>
<title value="Site Eligibility"/>
<status value="active"/>
<experimental value="false"/>
<date value="2025-06-23T22:09:21+03:00"/>
<publisher value="HL7 Saudi Arabia"/>
<contact>
<name value="HL7 Saudi Arabia"/>
<telecom>
<system value="url"/>
<value value="http://test-project.org/test-publisher"/>
</telecom>
</contact>
<description
value="This code set includes codes indicating the eligibility of the coverage at the identified site."/>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="SA"/>
<display value="Saudi Arabia"/>
</coding>
</jurisdiction>
<copyright value="nphies 2020+ (https://nphies.sa)"/>
<caseSensitive value="true"/>
<compositional value="false"/>
<versionNeeded value="false"/>
<content value="complete"/>
<concept>
<code value="eligible"/>
<display value="Eligible"/>
<definition value="Code to be used when the patient is eligibile"/>
<designation>
<language value="ar"/>
<value value="مؤهل"/>
</designation>
</concept>
<concept>
<code value="not-active"/>
<display value="Member's insurance policy is not active"/>
<definition
value="When HCP sends an eligibility request for an expired or canceled member’s policy on the eligibility service date."/>
<designation>
<language value="ar"/>
<value value="بوليصة التأمين لهذا العضو غير سارية"/>
</designation>
</concept>
<concept>
<code value="not-covered"/>
<display value="Policy does not cover the requested services"/>
<definition
value="When HCP sends an eligibility request mentioning a department that offers services out of patient policy coverage."/>
<designation>
<language value="ar"/>
<value value="البوليصة لاتغطي الخدمات المطلوبة"/>
</designation>
</concept>
<concept>
<code value="out-network"/>
<display value="Provider outside member Network"/>
<definition
value="Facility is outside the member covered policy network."/>
<designation>
<language value="ar"/>
<value value="مقدم الخدمة لا ينتمي إلي شبكة التأمين"/>
</designation>
</concept>
<concept>
<code value="provider-contract-suspended"/>
<display value="Provider contract is suspended"/>
<definition
value="Provider can be suspended for any reason (regulation, contractual, legal… etc.)"/>
<designation>
<language value="ar"/>
<value value="التعاقد مع مقدم الخدمة معلق"/>
</designation>
</concept>
<concept>
<code value="coverage-suspended"/>
<display value="Patient coverage is suspended"/>
<definition
value="Insurance coverage can be suspended for any reason (regulation, financial, legal, etc.)"/>
<designation>
<language value="ar"/>
<value value="تغطية هذا المريض معلقة"/>
</designation>
</concept>
<concept>
<code value="not-direct billing"/>
<display value="Patient is not covered on direct billing basis"/>
<definition
value="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)"/>
<designation>
<language value="ar"/>
<value value="المريض غير مغطى على أساس السداد المباشر"/>
</designation>
</concept>
<concept>
<code value="limit-exhausted"/>
<display value="Patient policy/benefit limit is exhausted"/>
<definition
value="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."/>
<designation>
<language value="ar"/>
<value value="الحد الأقصى لهذه الميزة التأمينية للمريض تم استهلاكه"/>
</designation>
</concept>
</CodeSystem>