IVF and fertility claims: what gets them refused
Two things refuse a ivf and fertility claim, and most clinic software checks neither: what this speciality gets wrong, and what your national claim rail rejects on top of it.
What ivf and fertility claims get refused for
These hold in every market, because they are about the clinical record rather than the submission format. Drapto checks them before a claim is sent rather than reporting them after it comes back.
- An IVF activity with no cycle reference.
- Payers reconcile every line to a cycle. A line that belongs to no cycle cannot be matched to the approval that covered it.
- An IVF procedure with no pre-authorisation.
- Almost every policy covering fertility requires prior approval per cycle, and the value makes this an expensive one to discover afterwards.
And what each rail refuses on top
Different in every market, and a system built for one will not catch another:
| Market | Rail | What refuses a claim | Clinic plan |
|---|---|---|---|
| United Arab Emirates | eClaimLink / DHPO | Pre-authorisation must be submitted within ONE HOUR of the physician order. | AED 1,800 |
| Saudi Arabia | NPHIES | Structural and clinical validation at submission — an ICD-10-AM code inconsistent with the stated DRG is rejected before a human reads it. | SAR 1,500 |
| Qatar | Seha / NHIC | Mandatory health insurance for expatriates since 2022; claims route through the national scheme rather than bilaterally. | QAR 1,850 |
| Philippines | PhilHealth eClaims 3.0 | Older versions were switched OFF on 31 March 2026. A facility that missed it cannot bill at all. | ₱9,650 |
| Brazil | TISS | Glosa codes are published by ANS, so rejections are diagnosable — but almost nobody validates before sending. | R$2,400 |
| India | ABDM | Structural validation before adjudication. | ₹9,599 |
Prices are for the market, not converted from anywhere.
Why both lists matter
A ivf and fertility claim that is clinically complete can still be refused on format, and one that is formatted perfectly can still be refused on substance. Most software checks one. The rejections that cost the most are the ones caught after submission, when the resubmission clock has already started.
Read the mechanism. Now check your own numbers.
Bring twenty settled claims, advices only, patient details redacted. We name the clause behind each reduction and you keep the findings.