NPHIES, known as the National Platform for Health Information Exchange System, is initiated by the Council of Health Insurance (CHI) and the National Center for Health Information (NHIC). It is spearheaded by the Sehati Company, driven by the vision of revolutionizing healthcare in the Kingdom of Saudi Arabia. This vision entails leveraging state-of-the-art technologies to elevate the standard and quality of healthcare services. NPHIES is designed to achieve this by consolidating precise and comprehensive data there by playing a pivotal role in realizing the implementation of Value-Based Healthcare (VBHC) and Diagnosis Related Groups (DRG).

The NPHIES platform consists of two key components: Insurance Services and Clinical Services, which include unified health records. Currently, the onboarding process is focused exclusively on Insurance Services. The onboarding procedure for Clinical Services will be conducted separately once that project is launched in the market.

Regarding the insurance services, NPHIES will serve as the central integration hub for all participants in the health insurance industry.  It will function as the centralized network and processing system, connecting all stakeholders to efficiently and effectively manage and monitor standards-based information exchanges between healthcare service providers and insurance payers, for claim management and processing.

The stakeholders involved in insurance services who would benefit from NPHIES integration are:

  • Healthcare providers (HCPs): hospitals, clinics, labs, medical centers, pharmacies, and other entities licensed by the CHI to recover the cost of healthcare services they provide from the private insurers.
  • Healthcare insurance companies (HICs): healthcare services insurers licensed by the CHI.
  • Third party administrators (TPAs): Service providers and claim administrative entities that assist healthcare insurance companies in administering their policies and networks.

Nuacare’s HMS(Hospital Management System) has achieved compliance for NPHIES insurance services. The company has successfully fulfilled the requirements of the NPHIES Vendor Certification Program, which allows Healthcare providers using Nuacare HMS to collaborate effectively with NPHIES. This collaboration ensures that the provider aligns with and adheres to the essential clinical, technical, and Business & Operational standards established within NPHIES.

Nuacare has completed the  prerequisites and testing procedures that culminated in the certification process. Currently, the Nuacare HMS system connected to NPHIES  is already operational at three sites, with ongoing efforts to expand its presence to additional locations.

The NPHIES insurance services support following use cases:

  • Check Eligibility Cycle
  • Request Pre-Authorization Cycle
  • Advanced Pre-Authorization Cycle
  • Cancel/Nullify Pre-Authorization Service
  • Process Claim Cycle
  • Request Claim Supporting Documents
  • Cancel/Nullify Claim Request 
  • Payment Reconciliation
  • Payment Confirmation Notification

Healthcare providers adopting Nuacare HMS can ensure a seamless integration with the NPHIES platform, resulting in cost-effectiveness and expedited project integration.

When healthcare providers sign up with Nuacare, they also gain access to an expert team that is well-versed in:

  • Nphies platform and its value proposition.
  • Nphies coding standards and guidelines and discerning their similarities and differences compared to the existing coding standards followed at each client organization.
  • Mapping of non-standard service lists to Nphies standard codes.
  • Interpreting and troubleshooting technical messages and error codes from Nphies and distinguishing between those related to the Nphies platform itself and those originating from information systems of the stakeholders.

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