NPHIES desk

Understand the rejection, fix it, and stop it coming back.

A bilingual reference built from NPHIES documents labelled public: every rejection code in plain language, a pre-check that runs on your device, and a plan for your type of facility.

Live todayThis reference deskOngoing integrationSending transactions to NPHIESDemonstration: the explanations and steps are BrainSAIT guidance still under review, so do not rely on them for a live claim decision. Independent reference. Not connected to or certified by NPHIES, and not issued by the Council of Health Insurance.

What a rejection code means, who owns it, and how to respond

All 71 official rejection reasons in plain language. The official wording comes from the NPHIES code sets. The explanations and steps are BrainSAIT guidance.

71 shown

AD-1-1The diagnosis does not fit this type of facility.

What to do Check the coded diagnosis and the provider type on your NPHIES account, then correct whichever is wrong.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Diagnosis is inconsistent with provider type

AD-1-2The diagnosis does not fit the clinician's recorded specialty.Clinician data

What to do Confirm the practice code sent in the care team matches the clinician's registered specialty.

Who owns it: Credentialing
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Diagnosis is inconsistent with clinician specialty

Check a clinician’s data readiness. BPR shows licence status as “not assessed” until the SCFHS integration is complete.

AD-1-3The diagnosis does not fit the encounter type.

What to do Check the encounter class first, because it is often the wrong field. Then recheck the diagnosis.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Diagnosis is inconsistent with encounter type

AD-1-4The diagnosis on the claim does not support this service.

What to do Link each service to the diagnosis that justifies it, and code the real indication.

Who owns it: Treating clinician
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Diagnosis is inconsistent with service/procedure

AD-1-5This type of facility is not expected to bill this service.

What to do Check the facility licence scope and the contract, then confirm the correct service code.

Who owns it: Payer contracts
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Service/procedure is inconsistent with provider type

AD-1-6The service does not fit the clinician's recorded specialty.Clinician data

What to do Confirm who performed the service and that the claim names that clinician with the right practice code.

Who owns it: Credentialing
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Service/procedure is inconsistent with clinician specialty

Check a clinician’s data readiness. BPR shows licence status as “not assessed” until the SCFHS integration is complete.

AD-1-7The service does not fit the encounter type.

What to do Check that the encounter class matches where the service actually took place.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Service/procedure is inconsistent with encounter type

AD-1-8The clinician's registration was invalid or expired for this service.Clinician data

What to do Check the licence with SCFHS for the date of service and update the practitioner record. Resend only if it was valid on that date.

Who owns it: Credentialing
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Clinician registration is invalid or expired

Check a clinician’s data readiness. BPR shows licence status as “not assessed” until the SCFHS integration is complete.

AD-1-9Member details on the claim do not match the insurer's record.

What to do Use the national ID or Iqama as the key, and copy the name and member number from the eligibility response.

Who owns it: Registration
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Mismatch in member information

AD-2-1The date of birth falls after the date of service.

What to do Look for a Hijri date typed in a Gregorian field. Enter dates in one calendar and convert only on display.

Who owns it: Registration
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Date of birth follows date of service/procedure

AD-2-2The record shows a date of death before the date of service.

What to do Verify the patient's identity and both dates. If the dates are right, escalate this before anything is resent.

Who owns it: Claims team
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Date of death precedes the date of service/procedure

AD-2-3The service happened before the coverage started.

What to do Run an eligibility check at booking and again on the day, and tell the patient about any cost in advance.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Date of service/procedure is prior to coverage effective date

AD-2-4The same service was already billed for this date.

What to do Check the claim's status before sending anything. Corrections go through a Prior Claim, not a brand-new claim.

Who owns it: Claims team
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Duplicate service/procedure code based on the date

AD-2-5The claim arrived after the submission window closed.

What to do Know each payer's window, review an ageing report weekly, and submit daily instead of in month-end batches.

Who owns it: Claims team
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Time limit for submission has expired

AD-2-6The service took place outside the authorisation's valid dates.

What to do Compare the service date with the validity period, and request an extension before the service next time.

Who owns it: Claims team
Route: Fix the authorisation. Request, amend or extend the authorisation. Do this before the service whenever you can. Provider Portal Manual, section 6.9
Official wording: Service was performed outside authorization validity date

AD-3-1This service did not need an authorisation.

What to do Do not chase the request. Proceed with the claim if the service is covered, and update your authorisation list.

Who owns it: Claims team
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Authorization not required for service/procedure

AD-3-2Separate codes were billed where one bundled code applies.

What to do Replace the separate lines with the bundled code from the current SBS list.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Use bundled code

AD-3-3Room services and food were billed apart from room and board.

What to do Remove those separate lines because room and board already includes them.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Room services and food are included in room and board expenses

AD-3-4The payer does not accept the DRG you calculated.

What to do Regroup the episode and compare the principal diagnosis, procedures and length of stay with the payer's recalculated DRG.

Who owns it: Medical coding
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Incorrect DRG calculated

AD-3-5The diagnosis does not fit the patient's age.

What to do Check the date of birth on file first, then the diagnosis code.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Diagnosis is inconsistent with patient's age

AD-3-6The diagnosis does not fit the patient's recorded gender.

What to do Check the gender on file first, then the diagnosis code.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Diagnosis is inconsistent with patient's gender

AD-3-7The service does not fit the patient's age.

What to do Check the date of birth on file first, then the service code's age limits.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Service/procedure is inconsistent with patient's age

AD-3-8The service does not fit the patient's recorded gender.

What to do Check the gender on file first, then the service code.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Service/procedure is inconsistent with patient's gender

CV-1-1Your facility is outside this member's network.

What to do Check the network at eligibility, and tell the patient before the service.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Provider is out of beneficiary network

CV-1-2Your facility is not eligible to provide this service under the policy.

What to do Check the contract's service scope and the member's class of cover.

Who owns it: Payer contracts
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Provider is not eligible for the service

CV-1-3The policy does not cover this diagnosis.

What to do Check the table of benefits before the service, and confirm the diagnosis is coded correctly.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Diagnosis is not covered

CV-1-4The policy does not cover this service.

What to do Check the table of benefits before the service, and agree any cost with the patient.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Service/procedure is not covered

CV-1-5The record does not show the service met the urgency criteria.

What to do Document why it was urgent, including the presentation, vital signs and the risk of waiting.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Service/procedure does not meet the criteria of urgency criteria

CV-1-6The payer treats this as a pre-existing condition that is not covered.

What to do Check the policy terms. If the record shows a later onset, send that evidence.

Who owns it: Claims team
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Pre-existing diagnosis/condition is not covered

CV-1-7The payer says the pre-existing condition was not disclosed.

What to do Record the onset accurately in the file, and raise the disclosure dispute with the payer.

Who owns it: Claims team
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Pre-existing diagnosis/condition was not disclosed

CV-1-8The annual limit or a sublimit has been reached.

What to do Check the remaining benefit before costly services, and tell the patient about any out-of-pocket amount.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Annual limit/sublimit amount exceeded

CV-1-9This consultation falls within the 14-day follow-up period.

What to do If it was a new, unrelated problem, make sure the diagnosis and the note show that clearly.

Who owns it: Claims team
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Consultation is within 14-day follow up period

CV-1-10The injury is work-related and the policy does not cover it.

What to do Ask about the cause of injury at registration, and direct the case to the correct occupational cover.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Work related injury is not covered

CV-2-1The patient is not a covered member.

What to do Run eligibility before the visit, and recheck the identifier used on the claim.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Patient is not a covered member

CV-3-1The benefit maximum for this period or occurrence has been reached.

What to do Check benefit use at eligibility, and agree any cost with the patient first.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Benefit maximum for this time period or occurrence has been reached

CV-3-2The service may be appropriate but is too frequent.

What to do Document why this repeat was needed, and include the earlier result if it supports the case.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Service/procedure may be appropriate, but too frequent

CV-3-3The service exceeds the number allowed in a lifetime.

What to do Check the patient's history for the service, then document the clinical need if you dispute this.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Service/procedure exceeds number of times per life

CV-3-4The service exceeds the number allowed under this policy.

What to do Check the count before the service, and agree any cost with the patient.

Who owns it: Registration
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Service/procedure exceeds number of times per policy

CV-3-5The service is above the policy's amount threshold in Saudi riyals.

What to do Check the policy threshold and the price list, then confirm the amount billed.

Who owns it: Payer contracts
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Service/procedure is above Saudi Riyals threshold per policy

CV-4-1The medication dose looks inappropriate.

What to do Check the dose against the indication, age and weight. Correct it, or document why this dose was intended.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Inappropriate medication dose

CV-4-2The medication duration looks inappropriate.

What to do Check the days of supply against the policy limit and the treatment plan.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Inappropriate medication duration

CV-4-3The authorised quantity is more than the prescribed quantity.

What to do Match the quantity to the prescription, and correct whichever record is wrong.

Who owns it: Pharmacy
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Authorization quantity exceeds prescription quantity

CV-4-4The prescription is out of date.

What to do Get a new prescription from the clinician before dispensing.

Who owns it: Pharmacy
Route: Fix the authorisation. Request, amend or extend the authorisation. Do this before the service whenever you can. Provider Portal Manual, section 6.9
Official wording: Prescription out of date

CV-4-5The medication is not on the formulary.

What to do Prescribe a listed alternative where suitable, or document why it is needed.

Who owns it: Treating clinician
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Medication is not listed in formulary

CV-4-6The milk product does not meet the coverage criteria.

What to do Document the clinical indication and the criteria it meets.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Milk Products do not meet coverage criteria

CV-4-7The device does not match the service or procedure.

What to do Check the device code and the procedure linked to it.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Device is not consistent with the service/procedure

CV-4-8The refill was requested too soon.

What to do Check the last dispense date and days of supply before refilling.

Who owns it: Pharmacy
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Refill too soon

CV-4-9This item is already included in another service.

What to do Remove the separate line, and keep a list of items included in each package.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Service/procedure/device/medication was included within another service/procedure

CV-4-10The device or medication is not approved by the Saudi FDA.

What to do Use an SFDA-registered product, and check the code against the current list.

Who owns it: Pharmacy
Route: Usually final. Resend only if the facts on the claim were wrong. Otherwise settle it with the patient under the policy and prevent it next time. BrainSAIT guidance
Official wording: Device/medications is not approved by the Saudi FDA

MN-1-1The payer finds the service is not justified by clinical guidelines.

What to do Send the clinical reasoning and the guideline you relied on, with the relevant results.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Service is not clinically justified based on clinical practice guideline, without additional supporting diagnosis

MN-1-2The patient is enrolled in hospice or palliative care.

What to do Confirm the enrolment status, and document how this service fits the care plan.

Who owns it: Treating clinician
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Patient is enrolled in hospice/palliative care

SE-1-1Vital signs are missing or inadequate.

What to do Send the recorded vital signs from the visit, and capture them at triage every time.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Vital signs are inadequate or missing

SE-1-2The history of present illness is missing or inadequate.

What to do Send the note with the onset, the course and the reason for the service.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: History of present illness is inadequate or missing

SE-1-3The chief complaint is missing or inadequate.

What to do Record a clear chief complaint for each visit, then send it.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Chief complaint is inadequate or missing

SE-1-4The physical examination is missing or inadequate.

What to do Send the examination findings that support the diagnosis.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Physical examination is inadequate or missing

SE-1-5The past medical history is missing or inadequate.

What to do Send the relevant history, including an explicit negative if there is none.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Past medical history is inadequate or missing

SE-1-6The investigation result is missing or inadequate.

What to do Attach the report that supports the service.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Investigation result is inadequate or missing

SE-1-7The type of diagnosis is missing or inadequate.

What to do Mark exactly one principal diagnosis, and set the correct type on the others.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Type of diagnosis is inadequate or missing

SE-1-8The treatment plan is missing or inadequate.

What to do Send a treatment plan that explains how this service fits in.

Who owns it: Treating clinician
Route: Send supporting information. After a complete response, send documents for the rejected or partly approved items. The payer reviews them and can reissue its response. Claim Resubmission Through Supporting Information guide
Official wording: Treatment plan is inadequate or missing

SE-1-9The quantity of the service is missing or inappropriate.

What to do Match the quantity to what was documented and delivered.

Who owns it: Medical coding
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Quantity of service/procedure is inappropriate or missing

SE-1-10The patient's occupation is missing or inappropriate.

What to do Capture the occupation at registration using the NPHIES occupation codes.

Who owns it: Registration
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Patient occupation is inappropriate or missing

BE-1-1The co-payment was not collected from the member.

What to do Collect the co-payment at the visit, and report the correct patient share on the item.

Who owns it: Registration
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Co-pay was not collected from member

BE-1-2The payer says the service was not performed.

What to do Check the record. If it was not delivered, remove it. If it was, send the evidence.

Who owns it: Compliance
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Service was not performed

BE-1-3The submission does not comply with your contract with this payer.

What to do Check the contract terms and the price list loaded for this payer.

Who owns it: Payer contracts
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Submission not compliant with contractual agreement between provider & payer

BE-1-4Pre-authorisation was required and was not obtained.

What to do Show each payer's list at ordering, and hold scheduling until the approval is attached.

Who owns it: Claims team
Route: Fix the authorisation. Request, amend or extend the authorisation. Do this before the service whenever you can. Provider Portal Manual, section 6.9
Official wording: Preauthorization is required and was not obtained

BE-1-5The claim does not match what was authorised.

What to do Match the code, side and quantity to the approval. If the plan changes, update the request first.

Who owns it: Claims team
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Claim information is inconsistent with preauthorized services

BE-1-6The amounts on the claim do not add up.

What to do Recalculate each item net as ((quantity × unit price) × factor) + tax, and make the total equal the sum of items.

Who owns it: Claims team
Route: Correct and resend. Send a new claim that references the original as a Prior Claim. Only the new version is considered. Provider Portal Manual, section 6.9
Official wording: Calculation discrepancy

BE-1-7The claim was billed under the wrong billing regime.

What to do Confirm your billing regime with the payer, including whether you are in DRG shadow or actual billing.

Who owns it: Payer contracts
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Incorrect billing regime

BE-1-8The appeal did not follow the procedure or missed its time limit.

What to do Check the contract's appeal steps, and track appeal dates per claim.

Who owns it: Claims team
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Appeal procedures not followed or time limits not met

BE-1-9The payer is recovering an earlier payment.

What to do Reconcile it against the payment notices, and ask for the basis in writing.

Who owns it: Payer contracts
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Recovery of Payment

BE-1-10The payer has flagged this as fraud.

What to do Stop and escalate to compliance and legal at once. Do not resend or change any record.

Who owns it: Compliance
Route: Review with the payer. A code change will not settle this. Check the contract and the facts, then take it up with the payer. BrainSAIT guidance
Official wording: Fraud