NPHIES: claims through the national platform

NPHIES is the national health insurance exchange in Saudi Arabia, run by the Council of Health Insurance. Any facility that bills an insurer submits eligibility checks, pre-authorisations and claims through it, and a clinic that cannot is paid late or not at all. Vendor guides describe claim rejections and delayed collection as the largest pain of clinics on the platform, with rejection rates of 20 to 35 percent where no structured denial process exists. A clinic system that keeps records and invoices in a claimable structure is the precondition; the connection itself is a certification project.

What it requires

• Connect to the platform through a certified integration for eligibility, pre-authorisation and claims
• Submit claims in the platform's HL7 FHIR message structure, with the coded services and diagnoses it expects
• Keep patient, visit, service and invoice data consistent so a claim can be traced back to the record
• Handle rejections: track each denial, correct it and resubmit within the insurer's window
• Record the insurer, the policy and the approval reference on every insured visit

What the system provides

• Patient, visit, service and invoice records structured so every claim field has a source in the record
• Insurer, policy and approval reference fields on the visit, with a per-visit trail
• A denial log: each rejected claim tracked with its reason, its correction and its resubmission date
• Invoices in the ZATCA format, so the insured and the self-paid parts of a visit reconcile

What we do not claim yet

• Submission to NPHIES itself is not built; it is planned with a certified integration partner, and no certification is claimed
• No eligibility or pre-authorisation call runs from our system today

Sources

• Asira: NPHIES guide for clinics (Arabic)
• MedCodex: NPHIES claim rejections and how to reduce them
• LogioLegion: practice management software with NPHIES, Nafath and ZATCA

These pages are engineering notes, not legal advice. Confirm your obligations with the regulator or a licensed adviser before you rely on them.