Intervention Combination Rules
The Social Health Authority (SHA) uses Combination Rules to govern which intervention codes can be added to the same claim.
These rules are essential for ensuring claim integrity, preventing conflicts (e.g., an inpatient and an outpatient service on the same claim), and improving payout times. Adhering to these rules at the point of care will significantly reduce claim rejections.
How to interpret the Combination Rules Table
The logic in the Combination Rules table is based on a Primary Intervention model. The first intervention you add to a visit sets the context for the entire claim.
The "Code" column below refers to the first intervention added to the visit. The "Allowed Code Combinations" column shows what other benefit packages can (or cannot) be added after that first one.
Checking Combinations via API
Before you call the Add Intervention endpoint to help add an intervention to a claim POST /.../add_intervention, you can validate your combination by using the Validate Add Intervention to a claim endpoint.This endpoint allows you to send your list of interventions and will return a response letting you know if it meets the combination rules or not for your existing claim, helping you prevent errors before they happen.
Intervention Code Combinations
| Code | Name of Package | Allowed Code Combinations |
|---|---|---|
| SHA-01 | Ambulance and Emergency Services | None. |
| SHA-03 | Critical Care Services | SHA-07 | SHA-06 | SHA-16 | SHA-09 | SHA-13 | SHA-08 | SHA-19 (Refer to surgical rules) |
| SHA-05 | Optical Health Services | ALONE (No other Intervention codes can/should be added) |
| SHA-06 | Haematology and Oncocllogy Services | ALONE (No other Intervention codes can/should be added) |
| SHA-07 | Inpatient Services | SHA-03 | SHA-06 | SHA-16 (001, 002, 004, 007, 008, 011) | SHA-09 | SHA-19 (Refer to surgical rules) |
| SHA-08 | Maternity and Child Health Services | SHA-03 | SHA-09 | SHA-07-005 | SHA-07-006 codes after the lapse of the global period as per the Maternity rules sheet |
| SHA-09 | Medical Imaging & Other Investigations | ALONE (No other Intervention codes can/should be added) |
| SHA-10 | Mental Wellness Services | ALONE (No other Intervention codes can/should be added) |
| SHA-12 | Outpatient Services | ALONE (No other Intervention codes can/should be added) |
| SHA-13 | Palliative Care services | SHA-03 | SHA-06 | SHA-07 | SHA-09 | SHA-16 | SHA-19 |
| SHA-16 | Renal Care Services | Codes to be reported alone are; SHA-16-001,002,004 Codes to allow combination are; * SHA-16-003 | SHA-03 | SHA-07 * SHA-16-005 | SHA-03 | SHA-07 * SHA-16-006 | SHA-03 | SHA-07 * SHA-16-007 | SHA-03 | SHA-07 * SHA 16-009 | SHA-03 | SHA-07 |
| SHA-18 | Essential Diagnostic Laboratory Listing for NCDs | ALONE (No other Intervention codes can/should be added) |
| SHA-19 | Surgical Services | SHA-07-002 | SHA-09 | SHA-03 & SHA-13 ONLY after the lapse of the surgical global period defined in the Surgical rules sheet |