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
ValueSet: Adjudication Reason
| Official URL: http://nphies.sa/terminology/ValueSet/adjudication-reason | Version: 0.3.0 | |||
| Active as of 2024-08-11 | Computable Name: AdjudicationReason | |||
Copyright/Legal: nphies 2020+ (https://nphies.sa) |
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Codes supporting the understanding of the adjudication result and explaining variance from the expected amount.
References
Logical Definition (CLD)
Generated Narrative: ValueSet adjudication-reason
version: 8; Last updated: 2024-08-11 11:52:01+0300
- Include all codes defined in
http://nphies.sa/terminology/CodeSystem/adjudication-reason
Expansion
ValueSet
Expansion performed internally based on codesystem Adjudication Reason v0.3.0 (CodeSystem)
This value set contains 71 concepts
| Code | System | Display (en-US) | Definition |
| BE-1-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service was not performed | Service was not performed |
| BE-1-10 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Fraud | Fraud |
| CV-4-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Medication is not listed in formulary | Medication is not listed in formulary |
| AD-2-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Date of birth follows date of service/procedure | Date of birth follows date of service/procedure |
| CV-4-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Authorization quantity exceeds prescription quantity | Authorization quantity exceeds prescription quantity |
| BE-1-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Co-pay was not collected from member | Co-pay was not collected from member |
| AD-1-7 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is inconsistent with encounter type | Service/procedure is inconsistent with encounter type |
| CV-4-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Prescription out of date | Prescription out of date |
| SE-1-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Vital signs are inadequate or missing | Vital signs are inadequate or missing |
| AD-2-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service was performed outside authorization validity date | Service was performed outside authorization validity date |
| CV-4-7 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Device is not consistent with the service/procedure | Device is not consistent with the service/procedure |
| CV-4-10 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Device/medications is not approved by the Saudi FDA | Device/medications is not approved by the Saudi FDA |
| AD-3-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is inconsistent with patient's age | Diagnosis is inconsistent with patient's age |
| CV-4-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Inappropriate medication duration | Inappropriate medication duration |
| BE-1-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Calculation discrepancy | Calculation discrepancy |
| CV-4-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Milk Products do not meet coverage criteria | Milk Products do not meet coverage criteria |
| CV-4-9 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure/device/medication was included within another service/procedure | Service/procedure/device/medication was included within another service/procedure |
| CV-1-10 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Work related injury is not covered | Work related injury is not covered |
| AD-1-9 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Mismatch in member information | Mismatch in member information |
| AD-1-8 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Clinician registration is invalid or expired | Clinician registration is invalid or expired |
| CV-4-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Inappropriate medication dose | Inappropriate medication dose |
| AD-3-7 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is inconsistent with patient's age | Service/procedure is inconsistent with patient's age |
| CV-4-8 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Refill too soon | Refill too soon |
| AD-3-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is inconsistent with patient's gender | Diagnosis is inconsistent with patient's gender |
| CV-2-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Patient is not a covered member | Patient is not a covered member |
| SE-1-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Chief complaint is inadequate or missing | Chief complaint is inadequate or missing |
| SE-1-7 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Type of diagnosis is inadequate or missing | Type of diagnosis is inadequate or missing |
| CV-1-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Pre-existing diagnosis/condition is not covered | Pre-existing diagnosis/condition is not covered |
| AD-2-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Date of death precedes the date of service/procedure | Date of death precedes the date of service/procedure |
| BE-1-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Preauthorization is required and was not obtained | Preauthorization is required and was not obtained |
| SE-1-10 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Patient occupation is inappropriate or missing | Patient occupation is inappropriate or missing |
| BE-1-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Claim information is inconsistent with preauthorized services | Claim information is inconsistent with preauthorized services |
| SE-1-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | History of present illness is inadequate or missing | History of present illness is inadequate or missing |
| CV-3-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure exceeds number of times per policy | Service/procedure exceeds number of times per policy |
| SE-1-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Past medical history is inadequate or missing | Past medical history is inadequate or missing |
| AD-2-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Date of service/procedure is prior to coverage effective date | Date of service/procedure is prior to coverage effective date |
| AD-3-8 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is inconsistent with patient's gender | Service/procedure is inconsistent with patient's gender |
| AD-1-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is inconsistent with provider type | Diagnosis is inconsistent with provider type |
| CV-1-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Provider is not eligible for the service | Provider is not eligible for the service |
| AD-1-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is inconsistent with encounter type | Diagnosis is inconsistent with encounter type |
| SE-1-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Investigation result is inadequate or missing | Investigation result is inadequate or missing |
| CV-1-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is not covered | Service/procedure is not covered |
| CV-1-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure does not meet the criteria of urgency criteria | Service/procedure does not meet the criteria of urgency criteria |
| SE-1-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Physical examination is inadequate or missing | Physical examination is inadequate or missing |
| AD-2-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Duplicate service/procedure code based on the date | Duplicate service/procedure code based on the date |
| AD-3-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Authorization not required for service/procedure during admitted care | Authorization not required for service/procedure during admitted care |
| CV-3-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure may be appropriate, but too frequent | Service/procedure may be appropriate, but too frequent |
| AD-1-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is inconsistent with clinician specialty | Diagnosis is inconsistent with clinician specialty |
| AD-2-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Time limit for submission has expired | Time limit for submission has expired |
| AD-1-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is inconsistent with provider type | Service/procedure is inconsistent with provider type |
| AD-1-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is inconsistent with service/procedure | Diagnosis is inconsistent with service/procedure |
| CV-1-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Provider is out of beneficiary network | Provider is out of beneficiary network |
| CV-1-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Diagnosis is not covered | Diagnosis is not covered |
| AD-3-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Use bundled code | Use bundled code |
| CV-3-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Benefit maximum for this time period or occurrence has been reached | Benefit maximum for this time period or occurrence has been reached |
| CV-3-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure exceeds number of times per life | Service/procedure exceeds number of times per life |
| AD-3-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Room services and food are included in room and board expenses | Room services and food are included in room and board expenses |
| BE-1-3 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Submission not compliant with contractual agreement between provider & payer | Submission not compliant with contractual agreement between provider & payer |
| BE-1-8 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Appeal procedures not followed or time limits not met | Appeal procedures not followed or time limits not met |
| AD-1-6 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is inconsistent with clinician specialty | Service/procedure is inconsistent with clinician specialty |
| BE-1-9 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Recovery of Payment | Recovery of Payment |
| AD-3-4 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Incorrect DRG calculated | Incorrect DRG calculated |
| BE-1-7 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Incorrect billing regime | Incorrect billing regime |
| CV-1-8 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Annual limit/sublimit amount exceeded | Annual limit/sublimit amount exceeded |
| CV-1-9 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Consultation is within 14-day follow up period | Consultation is within 14-day follow up period |
| CV-1-7 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Pre-existing diagnosis/condition was not disclosed | Pre-existing diagnosis/condition was not disclosed |
| CV-3-5 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service/procedure is above Saudi Riyals threshold per policy | Service/procedure is above Saudi Riyals threshold per policy |
| SE-1-9 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Quantity of service/procedure is inappropriate or missing | Quantity of service/procedure is inappropriate or missing |
| SE-1-8 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Treatment plan is inadequate or missing | Treatment plan is inadequate or missing |
| MN-1-2 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Patient is enrolled in hospice/palliative care | Patient is enrolled in hospice/palliative care |
| MN-1-1 | http://nphies.sa/terminology/CodeSystem/adjudication-reason | Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis | Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis |
Explanation of the columns that may appear on this page:
| Level | A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies |
| System | The source of the definition of the code (when the value set draws in codes defined elsewhere) |
| Code | The code (used as the code in the resource instance) |
| Display | The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application |
| Definition | An explanation of the meaning of the concept |
| Comments | Additional notes about how to use the code |