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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.

What the insurer’s message says: “[NPHIES display text for CV-1-4]”

In our own words, from the NPHIES Codeable Concept list v5.4. Reviewed by [name, role], [date].

GroupCoverage and eligibility
Who usually fixes itFront desk, at check-in
Deadline15 days from the rejection

What it means

For example: A patient on a basic class has a dermatology procedure their plan excludes.

The rejection is about the claim as it was sent, not about whether the care was right.

Why it usually happens

  • The service is excluded from the patient’s class or plan.
  • The policy covers it only up to a limit that has already been used.
  • The service was coded as something the policy doesn’t list.

How to fix this claim

  1. Check the patient’s class and benefits for this service in the insurer’s answer.
  2. If the service was coded wrongly, correct the code and resend before the deadline.
  3. If it really isn’t covered, agree with the patient that they pay for it themselves.
Mind the deadline. You have 15 days from the rejection to answer it (CHI Unified Health Insurance Contract, clause 5.4). Your contract with the insurer may set a different window, so check it.

How to stop it next time

Check cover and benefits before the visit, and tell the patient their share before the service, not after.

This page explains the common causes. Your insurer’s policy and your contract decide each claim.

Before sending

Nabdah catches this before you send.

The claim check flags a service the patient’s plan doesn’t cover, before anyone presses send.

Book a 30-minute demoChat on WhatsApp
CLM-2026-01067 · Nasser Al-MutairiChecked before sendingHeld
Services the plan coversFix
Patient’s cover activeChecked
Price matches the contractChecked
Sample · fix 1, then send

Often seen with

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
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

All rejection codes