Healthcare Financial Services IG Edition 1
0.4.0 - STU-Ballot with Updates
Healthcare Financial Services IG Edition 1
0.4.0 - STU-Ballot with Updates
Healthcare Financial Services IG Edition 1 - Local Development build (v0.4.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://nphies.sa/terminology/ValueSet/adjudication-reason | Version: 0.4.0 | |||
| Active as of 2024-08-11 | Computable Name: AdjudicationReason | |||
Copyright/Legal: nphies 2020+ ( https://nphies.sa ) |
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Valueset of codes supporting the understanding of the adjudication result and explaining variance from the expected amount.
References
version: 8; Last updated: 2024-08-11 11:52:01+0300
http://nphies.sa/terminology/CodeSystem/adjudication-reason version 📦0.4.0
Expansion performed internally based on codesystem Adjudication Reason v0.4.0 (CodeSystem)
This value set contains 71 concepts
| System | Code | Display (en) | JSON | XML |
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-2 | Service was not performed | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-10 | Fraud | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-5 | Medication is not listed in formulary | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-2-1 | Date of birth follows date of service/procedure | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-3 | Authorization quantity exceeds prescription quantity | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-1 | Co-pay was not collected from member | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-7 | Service/procedure is inconsistent with encounter type | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-4 | Prescription out of date | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-1 | Vital signs are inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-2-6 | Service was performed outside authorization validity date | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-7 | Device is not consistent with the service/procedure | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-10 | Device/medications is not approved by the Saudi FDA | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-5 | Diagnosis is inconsistent with patient's age | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-2 | Inappropriate medication duration | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-6 | Calculation discrepancy | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-6 | Milk Products do not meet coverage criteria | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-9 | Service/procedure/device/medication was included within another service/procedure | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-10 | Work related injury is not covered | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-9 | Mismatch in member information | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-8 | Clinician registration is invalid or expired | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-1 | Inappropriate medication dose | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-7 | Service/procedure is inconsistent with patient's age | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-4-8 | Refill too soon | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-6 | Diagnosis is inconsistent with patient's gender | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-2-1 | Patient is not a covered member | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-3 | Chief complaint is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-7 | Type of diagnosis is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-6 | Pre-existing diagnosis/condition is not covered | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-2-2 | Date of death precedes the date of service/procedure | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-4 | Preauthorization is required and was not obtained | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-10 | Patient occupation is inappropriate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-5 | Claim information is inconsistent with preauthorized services | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-2 | History of present illness is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-3-4 | Service/procedure exceeds number of times per policy | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-5 | Past medical history is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-2-3 | Date of service/procedure is prior to coverage effective date | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-8 | Service/procedure is inconsistent with patient's gender | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-1 | Diagnosis is inconsistent with provider type | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-2 | Provider is not eligible for the service | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-3 | Diagnosis is inconsistent with encounter type | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-6 | Investigation result is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-4 | Service/procedure is not covered | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-5 | Service/procedure does not meet the criteria of urgency criteria | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-4 | Physical examination is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-2-4 | Duplicate service/procedure code based on the date | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-1 | Authorization not required for service/procedure during admitted care | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-3-2 | Service/procedure may be appropriate, but too frequent | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-2 | Diagnosis is inconsistent with clinician specialty | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-2-5 | Time limit for submission has expired | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-5 | Service/procedure is inconsistent with provider type | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-4 | Diagnosis is inconsistent with service/procedure | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-1 | Provider is out of beneficiary network | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-3 | Diagnosis is not covered | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-2 | Use bundled code | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-3-1 | Benefit maximum for this time period or occurrence has been reached | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-3-3 | Service/procedure exceeds number of times per life | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-3 | Room services and food are included in room and board expenses | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-3 | Submission not compliant with contractual agreement between provider & payer | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-8 | Appeal procedures not followed or time limits not met | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-1-6 | Service/procedure is inconsistent with clinician specialty | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-9 | Recovery of Payment | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | AD-3-4 | Incorrect DRG calculated | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | BE-1-7 | Incorrect billing regime | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-8 | Annual limit/sublimit amount exceeded | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-9 | Consultation is within 14-day follow up period | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-1-7 | Pre-existing diagnosis/condition was not disclosed | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | CV-3-5 | Service/procedure is above Saudi Riyals threshold per policy | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-9 | Quantity of service/procedure is inappropriate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | SE-1-8 | Treatment plan is inadequate or missing | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | MN-1-2 | Patient is enrolled in hospice/palliative care | ||
http://nphies.sa/terminology/CodeSystem/adjudication-reason | MN-1-1 | 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 |