Medical Insurance & Billing FAQ (Saudi Arabia)

NPHIES (the National Platform for Health Insurance Exchange Services) is Saudi Arabia's national health-insurance exchange. It connects providers, insurers and regulators on one platform and carries eligibility checks, prior authorizations, claims and remittance advice. It is built on HL7 FHIR, so data must be exchanged in the expected structured format.

Diagnoses are coded with ICD-10-AM (10th edition) and procedures with ACHI (10th edition). Outpatient and dental billing also uses the Saudi Billing System (SBS, currently v3). Saudi Arabia does not use ICD-9.

AR-DRG (Australian Refined Diagnosis Related Groups) is the case-mix classification that groups inpatient episodes into resource-homogeneous categories. Saudi Arabia uses AR-DRG version 9.0 under NPHIES to support the shift from fee-for-service to case-based payment.

No. DRG payment is prospective: the group is assigned for the episode and determines the payment. It is not a fee-for-service model that can be billed retroactively, and KSA does not publish a single national price schedule — prices come from each provider's agreed service list and insurer contracts.

Rejections are broadly technical or medical. Technical rejections come from schema or format errors, missing eligibility or authorization data, or identifier mismatches. Medical rejections come from coverage, medical-necessity or coding and documentation issues. Most are preventable with cleaner front-desk data capture and pre-submission scrubbing.

CCHI (the Council of Cooperative Health Insurance) is the Saudi regulator for cooperative health insurance. It sets the rules insurers and providers must follow and oversees compliance and classification.

MedSure combines an enterprise revenue-cycle platform with consulting and training. Engagements typically start with an audit of your billing and insurance operations, followed by process fixes, staff training and ongoing KPI monitoring. Contact us to scope your facility.

No. The DRG Complexity Analyzer is part of the MedSure platform, which is a paid service. Access is provided to engaged clients; contact us to request access.

Yes. Training is delivered on-site at your facility or online, in Arabic and English, and is tailored to the roles within your team.

Every facility is different, so we scope engagements around your size, specialties and data quality. We usually begin with a focused audit so you can see the revenue impact of your current coding before committing to a wider programme.