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Fatimah Al-Zahrani

PA-2026-0083·Upper GI endoscopy, diagnostic·Al Salam Cooperative Insurance·Al Noor Polyclinic
National ID108733••••·Service date 24 Aug 2026
ExceptionPerson must decide
SAR 2,400
Confidence · lowest of 6 steps0.95RecommendationReturn to the physician

The money

Every figure derives from the coverage and the payer’s rules.

Requested
SAR 2,400
Benefit remaining
SAR 23,900
Payer would cover
SAR 2,400
Copay (class A)
10% · SAR 240
Patient balance
SAR 240

What stands in the way

The rules that stop this case, whatever the confidence score says.

2 things stand in the way of this case, and they need different people.

  • MN-021 documentation requirement not met

    Alarm symptoms, or a failed 8-week PPI trial — nothing in the note evidences alarm symptoms. Submitting now predicts an MN-02 rejection.

  • MN-011 payer criterion not met

    Age 50 or over with new dyspepsia, or alarm features. Submitting now predicts an MN-01 denial.

The record

The clinical note, with the facts read from it highlighted in place.

Clinical note · Dr. A. Nour2 evidence spans read

37F, epigastric pain and reflux 2 months. Started omeprazole 20mg 3 weeks ago, partial relief. No weight loss, no dysphagia, no melena. Haemoglobin 12.8.

What each agent did

Each step, how sure it was, and the evidence it read.

Agent trace
MN-021 documentation requirement not met. Alarm symptoms, or a failed 8-week PPI trial — nothing in the note evidences alarm symptoms. Submitting now predicts an MN-02 rejection.

Checks every documentation requirement the payer publishes for this service against the facts read out of the clinical note. A gap becomes a physician task carrying the exact missing items — not a rejection three days later.Deterministic: Required-field checklists per service, per payer. Judgement: Note comprehension and gap detection.

Alarm symptoms, or a failed 8-week PPI trial
Alarm symptoms, or a failed 8-week PPI trial — nothing in the note evidences alarm symptoms.
medication history
Started omeprazole 20mg

Completed in 1.6s.

MN-011 payer criterion not met. Age 50 or over with new dyspepsia, or alarm features. Submitting now predicts an MN-01 denial.

Medical necessity narrative · 0/1 criteria

Drafted in English and Arabic, from the criteria matrix only

Klik review · confirm before use
English

Upper GI endoscopy, diagnostic is requested, but none of UGIE's criteria are evidenced in the note. No justification can be drafted until the record supports at least one.

العربية

الإجراء المطلوب: Upper GI endoscopy, diagnostic. تم استيفاء 0 من 1 من معايير شركة التأمين بناءً على التوثيق السريري المرفق، مع الإشارة إلى المقاطع الداعمة في التقرير الطبي.

The gate

A named person approves before anything reaches NPHIES.

Return to the physician

A person approves every outbound submission. Approving writes your name to the audit trail against this case.

What the payer will say

Denied

Required documentation missing: Alarm symptoms, or a failed 8-week PPI trial.

Predicted from the payer’s published rules and this record. A different answer would mean the record or the rules have changed.