Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot
Healthcare Financial Services IG Edition 1
0.3.0 - STU-Ballot
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
| Official URL: http://nphies.sa/terminology/ValueSet/siteEligibility | Version: 0.3.0 | |||
| Active as of 2024-08-15 | Computable Name: SiteEligibility | |||
Copyright/Legal: nphies 2020+ (https://nphies.sa) |
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The codes used to convey Eligibility for services rendered at a specified service site.
References
version: 7; Last updated: 2024-08-15 14:37:44+0300
http://nphies.sa/terminology/CodeSystem/siteEligibility
Expansion performed internally based on codesystem Site Eligibility v0.3.0 (CodeSystem)
This value set contains 8 concepts
| Code | System | Display (en-US) | Definition |
| eligible | http://nphies.sa/terminology/CodeSystem/siteEligibility | Eligible | Code to be used when the patient is eligibile |
| not-active | http://nphies.sa/terminology/CodeSystem/siteEligibility | 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. |
| not-covered | http://nphies.sa/terminology/CodeSystem/siteEligibility | Policy does not cover the requested services | When HCP sends an eligibility request mentioning a department that offers services out of patient policy coverage. |
| out-network | http://nphies.sa/terminology/CodeSystem/siteEligibility | Provider outside member Network | Facility is outside the member covered policy network. |
| provider-contract-suspended | http://nphies.sa/terminology/CodeSystem/siteEligibility | Provider contract is suspended | Provider can be suspended for any reason (regulation, contractual, legal… etc.) |
| coverage-suspended | http://nphies.sa/terminology/CodeSystem/siteEligibility | Patient coverage is suspended | Insurance coverage can be suspended for any reason (regulation, financial, legal, etc.) |
| not-direct billing | http://nphies.sa/terminology/CodeSystem/siteEligibility | 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) |
| limit-exhausted | http://nphies.sa/terminology/CodeSystem/siteEligibility | 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. |
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 |