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Rejection library

Common NPHIES rejections, each explained with its fix.

Type the code from the rejection to see what it means and how to fix the claim. Free, with no account.

Updated [date]. 12 codes explained, in our own words, from the NPHIES Codeable Concept list v5.4. NPHIES files each reason under AD, BE, CV, MN or SE; we group them by what you’re looking for.

Coverage and eligibility

CV-1-4

Service not covered by the policy

The patient’s policy doesn’t include this service, so the insurer won’t pay for it under this claim.

Front desk, at check-in
CV-2-1

Patient not a covered member

The insurer can’t match the patient to an active member on the policy for the date of the visit.

Front desk, at check-in

Prior approval

BE-1-4

No prior approval

The insurer needed a prior authorisation for this service, and none was on the claim.

Front desk or billing, before the service
BE-1-5

Claim differs from what was approved

The claim doesn’t match the approval: a different service, more units, or a higher amount than the insurer agreed.

Billing, with the doctor

Medical necessity

MN-1-1

Not justified without a supporting diagnosis

The insurer couldn’t see a diagnosis on the claim that justifies the service.

The doctor, in the visit note
AD-1-4

Diagnosis does not support the service

There is a diagnosis on the claim, but the insurer doesn’t accept it as a reason for this service.

The doctor, in the visit note

Coding and billing

AD-3-2

A bundled code was needed

Services that should have been billed together, under one code, were billed separately.

Billing
BE-1-6

Claim amounts do not add up

The totals on the claim don’t match its lines: the sum, the patient’s share or the tax.

Billing

Missing documents

SE-1-1

Vital signs missing

The insurer needed the patient’s vital signs for this claim, and they weren’t on it.

The nurse, before the doctor
SE-1-6

Test result missing

The claim needed a test result to support it, and none was attached.

Billing, with the lab

Duplicates and time limits

AD-2-4

Same service billed twice

The insurer already has a claim for this service, for this patient, on this date.

Billing
AD-2-5

Sent after the time limit

The claim reached the insurer after the time allowed for sending it.

Billing
Before sending

Caught before sending, not rejected after.

Several of these reasons can be seen before the claim leaves the clinic. Nabdah checks for them, and your team presses send.

  • Cover checked with NPHIES at check-in
  • Approval number checked on the claim
  • Price taken from the contract
  • Your team presses send
CLM-2026-01067 · Nasser Al-MutairiChecked before sendingHeld
Authorisation on fileFix
Patient’s cover activeChecked
Price matches the contractChecked
Sample · fix 1, then send