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مجلس الضمان الصحي التعاوني مجلس الضمان الصحي التعاوني
 
 
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What is NPHIES?

The unified electronic services platform is National Platform for Health and Insurance Exchange Services launched by the Cooperative Health Insurance Council (CCHI) and the National Center for Health Information (NHIC) and led by the Sehati Company

Vision


Transforming the health care sector in the Kingdom of Saudi Arabia by using the latest technologies to enhance the level and quality of health services

Value Proposition


Consolidated, accurate and comprehensive data; supporting the achievement of Value Based Healthcare (VBHC ) and Diagnosis Related Group (DRG)

NPHIES Component​

Insurance Services


Digital Standard insurance Services aims to govern health insurance services by connecting all stakeholders in health insurance (health service providers, health insurance companies).

Clinical Services

Unified digital health services (unified health record) for patients in the Kingdom of Saudi Arabia aims to improve the efficiency and quality of health care services provided, and also reduces the cost and time of providing health care services, which is a basis for improving healthcare decision-making


​NPHIES​ Target Audience

Clinical Services
Financial Services
Healthcare Providers Governmental and Privet Sectors
Health Insurance Companies
Third Party Administrators ​​

                                                                             Eligibility Management Services      

Check Eligibility
Pre-Authorize Health Service
Resubmit Pre-Authorization
Send Advanced Pre-Authorization
Nullify Pre-Authorization Request
Cancel Pre-Authorization
Retrieve Beneficiary Policy Details
Notify Pre-Authorization

User Management Services                                                                                      

Register Accredited Enterprise
Manage Enterprise
Block/Unblock Stakeholder
Manage User Registration
Manage Access to Enterprise Representative

​Claim(s) Management Services                                                                                ​

Process Claim(s)
Re-Adjudicate Claim(s)
Amend Claim
Revise Claim/Invoice Notification
Inquire Claim Status
Nullify Claim
Validate Claim Author Offline

CCHI Insurance Management Services                                                                   

Send HCP Network
Send Policy to MOI
Report Fraud/ Misuse
Raise a Complaint
Track Complaint
Validate Health Practitioner Status
Detect Fraud/Misuse
Generate Reports
Request Claim Supporting Documents

Payment Management Services                                                                                

Payment Advice Notification
Payment Confirmation Notification
Patient ID Management
Coded Lab Order
Medication Dispensation
Encounter Summary
Surgical Notes
Provide/ Organization Management
Sharing Diagnostic Imaging
Medication Prescription
Baby Discharge Summary
Referral Request/ Response
Coded Lab Results
Tele-Radiology Ordering
General Purpose Discharge Summary
Mother Discharge Summary
Immunization Record

Release 1

Insurance Component

  • Insurance  Services
  • Registration Services*​
  • Data Base and BI
  • Infrastructure Services

Release 2

NPHIES Clinical Services

  • Patient Portal with SSO **
  • Health Service Providers Portal
  • Photo viewer
  • Date of examination
  • Clinical documents (6 Use Cases)

Release 3

NPHIES Clinical Services

  • Healthy data warehouse
  • Other deferred services, such as (BAM, API manager)

Release 4

NPHIES Clinical Services

  • Clinical Documentation (9 Use Cases)

Notes:

The provided final list of services in release 2, release 3 and release 4 will be reviewed and approved before submission offers.
“NHIC” the existing registration services, will be used later to transfer both records and terminologies to the second version UniPlat Portal will be emerged with SSO's into release 2
 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

General Circular Number 1 of 2020 (GC​ 01-2020)


General overview of NPHIES

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Policy Directive Number 1 of 2020 (PD 01-2020)

Mandatory participation in market assessment, awareness and training events

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Technical Update Number 1 of 2020 (TU 01-2020)


Portal participation: hardware and software requirements

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Technical Update Number 2 of 2020 (TU 02-2020)

Types of NPHIES Financial Services transactions

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

General Circular Number 2 of 2020 (GC 02-2020)

Roles and responsibilities

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Policy Directive​ Number 2 of 2020 (PD 02-2020)

Roles and responsibilities

​​
 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Technical Update Number 3 of 2020 (TU 03-2020)

Types of NPHIES Financial Services transactions

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

General Circular Number 3 of 2020 (GC 03-2020)

monitoring and compliance​

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Policy Directive​ Number 3 of 2020 (PD 03-2020)

NPHIES fees​

 
Enabling Provisions Notice pursuant to the implementation of the NPHIES system

Policy Directive​ Number 4 of 2020 (PD 04-2020)

Billing code sets

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​ ​​

 CCHI Billing System 

This billing procedure has been developed by CCHI to ease for health care providers coding health services as will billing their invoices insurance companies. It has been developed based on ACHI. This billing procedure are compatible with standards and classifications that are acceptable by SHC.

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Coding fields required Codes, classifications and terminologies to be used
Description
Diagnosis Codes, includes: Ophthalmology, Rehabilitation ICD-10-AM Tenth Edition
الترميز الطبي الأسترالي للأمراض والتشخيص
Procedures / Health interventions (in-patient) includes: Ophthalmology, Rehabilitation and allied health services CCHI Billing System (CCHI-BS) قائمة الترميز للإجراءات والعمليات
Outpatient Cost/ Ambulatory Services, Consultation, Room and Board, Inpatient Rounding CCHI Billing System (CCHI-BS) قائمة ترميز الإجراءات للعيادات الخارجية والتكلفة
Medical devices GMDN = classification of devices per intended use and specification التصنيف والترميز للمعدات والأجهزة الطبية ومجموعاتها
Oral Health

Inpatient: CCHI Billing System (CCHI-BS)

 

Outpatient: The Australian Schedule of Dental Services and Glossary (ADA)

قائمة الترميز للتنويم والعمليات لخدمات طب الأسنان

 

الترميز للعيادات الخارجية: جدول خدمات طب الأسنان الأسترالي

Laboratory tests, observations and Blood Bank products CCHI Billing System (CCHI-BS) الترميز للاختبارات التحليلية وبنوك الدم
Imaging Procedures CCHI Billing System (CCHI-BS) الترميز والتصنيف للأشعة
Packaged pharmaceuticals SFDA (GTIN) ترميز تصنيف الأدوية
Ambulance and Transportation Services (SRCA) CCHI Billing System (CCHI-BS) ترميز النقل الإسعافي للمرضى وحالاتهم

Clinical Standards

​To ease the communication amongst health ecosystems harmonies, a unified language should exist to assure all speak to each other in an acceptable format. While CCHI is developing the national platform for the health insurance exchange system (NPHIES), it also has been investing with other stakeholders to make sure that all health services standards are in place and agreed through Saudi Health Council SHC. These standards besides the data that are provided by the national health information center (NHIC), (such as the Australian Diagnosis coding ICD-10-AM) will lead to a more effective and efficient healthcare system. Also, working with these standards will enhance the healthcare sector's transparency and sustainability. 

 

For more information about medical standards please refer to the NHIC website 

( please click here​​)



Coding fields required Codes, classifications and terminologies to be used Description
Demographics/Administrative Coding Saudi Health Data Dictionary (SHDD), V.2 المصطلحات الطبية والإدارية المستخدمة في المؤسسات الصحية
Diagnosis Codes, includes: Ophthalmology, Rehabilitation ICD-10-AM/ACHI/ACS Tenth Edition الترميز الطبي الأسترالي للأمراض والتشخيص
Procedures / Health interventions (in-patient) includes: Ophthalmology, Rehabilitation and allied health services ACHI Tenth Edition الترميز الطبي الأسترالي للإجراءات والعمليات
Allergies

SNOMED CT

Encode Allergies

نظام الترميز والمصطلحات الطبية

SNOMED CT

ترميز الحساسية

Emergency Department Principal Diagnosis

ICD-10-AM/ACHI/ACS Tenth Edition

MDC and URG

الترميز الطبي الأسترالي للحالات الإسعافية وتشخيصها
Medical devices GMDN = classification of devices per intended use and specification التصنيف والترميز للمعدات والأجهزة الطبية ومجموعاتها
Functional Assessments International Classification for Functioning, Disability and Heath (ICF), (FIM (Functionality Independence Measures)) الترميز والتصنيف للإعاقة والعلاج الوظيفي
Oral Health

Inpatient: ICD 10 AM + ACHI

Outpatient: The Australian Schedule of Dental Services and Glossary (ADA)

الترميز للتنويم والعمليات: نظام الترميز الأسترالي

 

الترميز للعيادات الخارجية: جدول خدمات طب الأسنان الأسترالي

Laboratory tests, observations and Blood Bank products LOINC and RELMA الترميز للاختبارات التحليلية وبنوك الدم
Imaging Procedures National Interim Clinical Imaging Procedure (NICIP) Code Set with Saudi Extensions الترميز والتصنيف للأشعة
Units of measures The Unified Code for Units of Measure (UCUM) Revision 2.1 التصنيف لمعيار الوحدات
Cause of Death / Morbidity ICD-10 WHO تصنيف أسباب الوفاة
Packaged pharmaceuticals SFDA (GTIN) ترميز تصنيف الأدوية
Herbal & Health Products SFDA Registration Number قائمة المستحضرات العشبية والصحية

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NPHIES Champions ​

“NPHIES Champions (SPoC)” In line with the Kingdom's Vision 2030, and to create synergies within the Healthcare Ecosystem (Healthcare Providers and Health Insurance Co.), we are delighted to announce the launch of NPHIES champion initiative. Please provide information as detailed and accurate as possible to ease the communication and the onboarding process. For more information Click here​​ ​

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Vendors Certification Program ​

​In order to become one of nphies certified vendors, kindly see below the requirements to get the certificate and have the ability to link nphies to the health care providers and the health care insurance:   


Available Resources ​

Documentation​​

Implementation Guide that includes:
Information Exchange Construction and Flow
Use Cases
Data Model

API Specs and Documentation 
Sample Messages 

Training

Access to group integration and technical training sessions including:
INT-01 – WS Integration Training
INT-02 – Onboarding Integration Solution Training

Limited dedicated consultation sessions

Support

Access to nphies Reference Implementation to:
Test development efforts
Simulate market scenarios and use cases prior to go-live


Limited dedicated support session during testing and simulation



If you are a system vendor and want to get a certification of nphies certified system vendor kindly send an email to: 

Or you can contact nphies contact center:
920004299 




Implementation Guide ​

Implementation guide will be used by Insurance (including TPAs) and providers to integrate with nphies. The guide describes the information exchange construction and flow between different healthcare stakeholders and the solution, use cases, defines the message structure of profiles for FHIR implementation, and specifies the links to relevant FHIR artifacts and documenta​tion​​​.

​​​

The documents are now available on nphies Community Portal website using the following link: Link  Documents can be found using the following pathway after logging into nphies Community Portal: Health Dictionary HD > Documentations > Technical Standards

If your entity is not part of wave 1 of nphies onboarding and you require access, please contact Link

Exchange Profiles​​ ​

​Standard profiles will define for each transaction the schema elements, fields, cardinality type, datatype, and minimum data sets.  There are four major profiles as below each having sub-profiles:

· ​Eligibility Request
· Eligibility Response
·  Authorization Request
·  Authorization Response
·  Claim Request
· Claim Response
· Payment Notification
· Payment confirmation

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​​​​​

The documents are now available on nphies Community Portal website using the following link: Link  Documents can be found using the following pathway after logging into nphies Community Portal: Health Dictionary HD > Documentations > Technical Standards

If your entity is not part of wave 1 of nphies onboarding and you require access, please contact Link

Business Rules and Validation Rules (BRVR)

The business and validation rules will be utilized to govern transaction use cases in line with the UniPlat use case profiles (such as eligibility checks, preauthorization requests, claims process cycle).
Business rules: Business rules will outline the workflows and business cycles governing the use of case transactions.  For example, an eligibility check response cannot come before an eligibility check request.
Validation rules: Validation rules will govern the syntax, minimum data set, and values utilized within the fields of the transactions.  For example, the encounter type field cannot be empty, and the value must be one of the predefined lists of values.​
​​​

The documents are now available on nphies Community Portal website using the following link: Link  Documents can be found using the following pathway after logging into nphies Community Portal: Health Dictionary HD > Documentations > Technical Standards

If your entity is not part of wave 1 of nphies onboarding and you require access, please contact Link


Denial Codes ​

​When payers have a reason to reject a claim, a denial code will be applied to the transaction which will generate a message to the provider.  The set of more than 80 denial codes are grouped into a benefit, clinical and operational and will cover a range of subjects such as:
·           Authorisation
·           Eligibility
·           Price
·           Claim
·           Coding
·           Dosage
·           Time​

The documents are now available on nphies Community Portal website using the following link: Link  Documents can be found using the following pathway after logging into nphies Community Portal: Health Dictionary HD > Documentations > Technical Standards

If your entity is not part of wave 1 of nphies onboarding and you require access, please contact Link


Use Cases ​

Use cases are a series of subroutines within the overall claims cycle. These subroutines are defined in the communication cycle between payers and providers within nphies. ​​​
​​

The documents are now available on nphies Community Portal website using the following link: Link  Documents can be found using the following pathway after logging into nphies Community Portal: Health Dictionary HD > Documentations > Technical Standards

If your entity is not part of wave 1 of nphies onboarding and you require access, please contact Link


NPHIES Training sessions ​​ ​

In the process of transitioning in NPHIES project from inception phase to activation phase, we are introducing series of training courses, to enable the market and provide them with the essential skills to implement the change and to develop a more detailed understanding of NPHIES and to ease the adaptation of the platform.

 

Note: All provided training sessions are considered mandatory for any entity to be certified to use NPHIES platform.


The training program is divided into Three specialized domains

​1. Standard Coding Training:

Standard Coding Training Courses focus on developing a high-level understanding of standard code sets in order to use them within the working environment. These codes are very important to simplify the processes and decrease the costs associated with every health care transaction.

 2. Business/Operational training:

Business and Operational Training Courses will focus more on specific areas of the implementation process, it is anticipated that the onboarding orientation sessions will encompass all generic project overviews regarding objectives, approach, and desired outcomes.

 3. Technical Training:

Technical Training Courses will be conducted using the integration tool kit (Material, guidelines, sample data, and web services) provided by NPHIES insurance core vendor. The course will provide details about NPHIES solution, registration, configuring, and utilization to perform the transaction, mapping, and communication.

 Training sessions are held weekly for those who have been invited from healthcare providers and health insurance companies.​


​ ​

​​ Within the framework of the digital transformation of the health sector in the Kingdom of Saudi Arabia and in order to achieve one of the vision's goals 2030 The council of cooperative insurance (CCHI) has lunched NPHIES initiative which is the unified electronic services platform is National Platform for Health and Insurance Exchange Services. Accordingly, the CCHI approved the list of entities to join the first wave of qualification and preparation of the NPHEIS initiative The list of entities to join the first wave was chosen based on market assessment and maturity level assessment. Accordingly, the council of cooperative health insurance will provide all possible support during the onboarding period.

Health Care Providers 
​مجموعة الحبيب شركة المواساة للخدمات الطبية شركة المركز الطبي الدولي المحدودة
شركة مستشفى الدكتور  سليمان عبدالقادر فقيه شركة الشرق الاوسط للرعاية الصحية شركة دله للخدمات الصحيه
شركة الحمادي للتنمية و الإستثمار الشركه الطبيه التخصصيه المحدوده شركة عيادات باقدو الطبية
مركز مغربي للبصريات
شركة مستشفيات ومراكز مغربي الطبية شركه مراكز العبير الطبيه
شركة مستشفى  الدكتور عبدالرحمن بخش  المحدوده مستشفى الموسى التخصصي شركة الاطباء المتحدون المحدودة
شركه خدمات المشاريع الطبيه المحدوده شركة المشاريع الطبية المتحدة المحدودة الحرس الوطني
شركه مستشفى غسان نجيب فرعون العام مستشفى محمد الدوسري مستشفى جدة الاهلي
شركة النهدي الطبية شركه الدواء للخدمات الطبيه  المحدوده شركة الانماء للخدمات الطبية
شركه اندلسيه العربيه القابضه للخدمات الطبيه  شركه مستشفى الامير فهد بن سلطان  
شركة سند الرحمة للرعاية الطبية​ 
​مستشفى ابها  الخاص  شركه اسطون للخدمات الطبيه المحدوده​  الشركة الوطنية للرعاية الطبية 
​شركة ناظر للعيادات الطبية  شركة تداوي للخدمات الطبيه  ​ ​​شركة مستشفى باقدو والدكتور محمد عرفان العام
​شركه ابراهيم محمد المانع واخوانه    ​ ​​


Health Insurance Companies and TPAs
​شركة بوبا العربية للتأمين التعاوني الشركة التعاونية للتأمين التعاوني شركة الراجحي للتأمين التعاوني
شركة عنايه السعوديه للتامين التعاوني شركة المتوسط والخليج للتأمين وإعادة التأمين التعاوني_ ميدغلف شركة الصقر للتأمين التعاوني
شركة الاتحاد التجاري للتأمين التعاوني شركة بروج للتأمين التعاوني الشركة العربية السعوديه للتامين التعاوني_ سايكو)
شركة الدرع العربي للتأمين التعاوني الشركة السعودية المتحدة للتأمين التعاوني_ولاء شركة التأمين العربية التعاونية
شركة سلامة للتأمين التعاوني شركة المجموعة المتحدة للتأمين التعاوني _ اسيج شركة إتحاد الخليج للتأمين التعاوني
شركة اكسا للتأمين التعاون شركة سوليدرتي السعودية للتكافل شركة أمانة للتأمين التعاوني
شركة ملاذ للتأمين وإعادة التأمين التعاوني الشركة الاهلية للتأمين التعاوني شركة متلايف والمجموعة الأمريكيه الدولية والبنك العربي الوطني للتامين التعاوني
شركة وفا للتأمين التعاوني شركة اليانز السعودي الفرنسي للتأمين التعاون الشركة المتحدة للتأمين التعاوني
الشركة الخليجية العامة للتامين التعاوني   شركة الأنماء طوكيو مارين  الشركة العالمية للتأمين التعاوني ​ 
Total Care Saudi Company - TPA  Saudi NextCare Company – TPA​  Saudi GlobeMed Company - TPA ​ 
Madarat National Company for the settlement of insurance claim - TPA  Saudi Arabian Mednet Company - TPA  ​ 
​​

If you any questions or concerns in this regard, please contact us on 920004299 or at the email Onboarding@cchi.gov.sa

​ ​
ICD 10 AM 10th edition as announced by CCHI.
ICD 10 WHO codes to be used in HIS to code the cause of death or morbidity services.
SFDA (Saudi Food and Drg Authority) codes and GTIN codes as announced by CCHI​
LOINC (Logical Observation Identifiers Names and Codes) version 2.65 as announced by CCHI.
local codes list/  Saudi Modified Ambulatory Classification as announced by CCHI.
Local codes list / Saudi modified ambulatory classification as announced by CCHI 
AR-DRG version 9.0 Grouper as announced by CCHI/ however, not to be implemented at this stage. 
This is NPHIES list for units of measures for reporting laboratory results as announced by CCHI.​
*NPHIES users have to map their codes to the published standards coders.
* The provider can utilize the closest standard code for mapping.
*some internal codes can have multiple matches (one to many mapping)

The mechanism will be announced by CCHI. 
Persons handling clinical / billing information should be trained (Doctors, Nurses, Billing staff, Insurance co-ordinators, Case Managers, RCM team, etc)​

Its provider's decision to hire professional coders for mapping / coding for accurate mapping/coding.

  • ​1)Clinical data will be in a unified format
  • 3)Will help in statistical studies/performance reviews
  • 4)Will help in improving clinical documentation
  • 5)Will be a door for strong and robust HIS system (Reimbursement/ decrease rejections/ smooth claims)
  • 6)In the future, it will help us in adopting VBHC
  • The provider needs to enter all the package components in standard coding, using the exact or closes code for each of the components separately
  • Package price will be assigned to the major code within the package, and the rest of the items will have a price as 0.
It depends on the contract between the Payer and Provider, to be finalized within the transition period.
The Fast Healthcare Interoperability Resources (FHIR - Pronounced "fire") is an interoperability standard intended to enable the exchange of healthcare data between different health systems
The major difference between FHIR and other standards is simplicity and flexibility. Fast – the F in FHIR – expresses the intent to make this standard faster to learn, develop and implement
Interoperability refers to the ability of applications to exchange and make use of information
The main transactions are: Eligibility (Request/Response),Authorization(Request/Reponse),Claim(Request/Response) and Payment(Notification and Confirmation)..etc
The list will be shared once finalized
The mandatory & optional data set fields have been identified based on the FHIR base resources and customized as per the Saudi market need.
Documentation will be provided once finalized
Yes, the session dates will be announced by CCHI
Yes. There are several requirements such as the Member Register and eligibility checks that will require insurers to participate in the system
All communications will be available on the Community Portal. In addition, direct communications will be made to each company's Single Point of Contact (SPoC). Regulatory requirements will take the form of Enabling Provisions Notices (EPNs), therefore you are kindly requested to keep your SPOC contact information updates on a regular basis
The CCHI implementing regulations require payers and providers to satisfy electronic transaction controls and requirements adopted by CCHI as a condition of their approval/accreditation
After the Transition period / Grace period you cant use your own systems, Uniplat will be the only form of communication between payers, providers, and CCHI
Over time all claims will need to be processed through the system.  For a temporary period paper-based claims can continue, please visit:https://www.cchi.gov.sa/en/Uniplat/Pages/default.aspx

Eligibility requests and responses, authorization requests and responses, authorization cancellations, all claims submissions, responses, revisions and resubmissions, and payment advice and confirmation are the main transactions
You will need to continue with paper-based transactions for these partners until they are onboarded to the platform
To communicate with SHIB only the standard code sets may be used.  For a temporary period, a mapping tool will be available to help map internal codes to the standard codes.
A free mapping tool will be available but will be allowed for a temporary period
Whilst there may be some initial extra costs these will be offset over time by the cost savings that the electronic claims system will produce for both payers and providers
This is not an option.  a list will be published detailing areas of non-compliance and associated sanctions and penalties to be imposed by CCHI, please visit:https://www.cchi.gov.sa/en/Uniplat/Pages/default.aspx​

Deadlines will be realistic and therefore no extensions will be allowed.
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Last Update : 11/29/2020 5:18 PM