Claims that clear first time.
Every claim, its scrub report and what the payer did with it. A blocked claim never went out — the scrubber caught pre-submission what NPHIES would have rejected after.
Khalid Al-Otaibi
GulfCare Takaful · Dar Al Shifa Hospital · 3 lines
John Okafor
Najm Health · Dar Al Shifa Hospital · 3 lines
Noura Al-Harbi
Al Salam Cooperative Insurance · Dar Al Shifa Hospital · 2 lines
- WarningAU-02 · line 2
NICU-OBS-1D is not on pre-auth ALS-PA-30119. Amend before submission, or expect this line to be denied.
Service not covered by the pre-authorization
- WarningBE-03
Pre-authorised lines bill above the approved amount on ALS-PA-30119. Expect a partial payment and a patient balance.
Benefit limit exceeded
Line 2 denied AU-02 — Service not covered by the pre-authorization.
A service was delivered that the pre-authorization never covered.
Amend if the window is open, otherwise a write-off or patient-bill decision.
Prevention rule proposed against Al Salam Cooperative Insurance: Raise an amendment task the moment a service line is added after approval, before discharge closes the window.
Ahmed Al-Rashidi
Al Salam Cooperative Insurance · Al Noor Polyclinic · 3 lines
Fatimah Al-Zahrani
Al Salam Cooperative Insurance · Al Noor Polyclinic · 1 line
- BlockAU-01 · line 1
Upper GI endoscopy, diagnostic is pre-auth required for this payer and the claim carries no preAuthRef. NPHIES would reject this outright.
Missing or invalid pre-authorization reference
John Okafor
Najm Health · Dar Al Shifa Hospital · 2 lines
- WarningCO-01 · line 2
R10.9 is too unspecific to support CT-ABDOMEN. Predicted CO-01 denial — recode against the note before submitting.
Diagnosis-procedure inconsistency or insufficient specificity
Line 2 denied CO-01 — Diagnosis R10.9 is insufficiently specific for CT-ABDOMEN.
The note documents "Clinically suspected acute appendicitis", which supports K35.80. The claim went out under R10.9, which the payer cannot adjudicate.
Recode R10.9 to K35.80 (Unspecified acute appendicitis) on the note evidence, and resubmit line 2.
Prevention rule proposed against Najm Health: Route any unspecified diagnosis on an imaging line through a specificity review before submission.