Reception
A yes or no at the counter, and the co-payment to take.
Saudi Arabia
NPHIES eligibility and claims for clinics
The expensive moment in insured care is not the claim. It is treating a patient whose cover did not extend to what you treated them for. Eligibility, pre-authorisation and claims run through NPHIES from inside the visit, so the answer arrives before the service does.
Eligibility checkRuns automatically when the appointment is booked — coverage, limit and co-pay come back before the patient sits down.Live
Automatic pre-approvalSubmits the treatment plan and returns the insurer decision without anyone rekeying it into a portal.Live
Claims sent1,284
Auto-approved1,141
Pending83
Claims
CLM-8841Balsam Al-NajjarMedGulfAuto-approved
CLM-8840Reem BodiahBupaPending
CLM-8839Arwa IdreesTawuniyaPartially
Checked before the patient is seen
An eligibility check that happens in a different window, run by whoever remembers, is a check that gets skipped on a busy morning. This one is part of arriving.
- Eligibility answered at the counter, against the policy on file
- Cover, limits and co-payment shown before the service is booked in
- Policy expiry flagged in advance rather than at the desk
- The response stored against the visit it belongs to
- A clear answer when the patient is not covered, before they are treated
Approvals raised from the work, not beside it
Pre-authorisation is a clinical request with a financial consequence. It is raised from the visit that needs it, with the documentation attached, and it comes back to the same place.
- Pre-authorisation raised from inside the visit
- Clinical documentation attached to the request
- Approval reference stored against the service it covers
- Outstanding approvals visible to whoever is booking
- Expiring approvals surfaced before they lapse
Claims followed to the money
A submitted claim is not revenue. What matters is what was paid, what was reduced, what was refused and why — and whether anyone did anything about it.
- Claims submitted from the invoice they belong to
- Status followed from submission to remittance
- Rejections grouped by reason, so the pattern is visible
- Partial payments reconciled against the original claim
- What each company actually pays, per service, over time
Who works with NPHIES
Insurance touches three jobs in a clinic, and they need different things from it.
Clinicians
Approval status for what they are about to do, in the visit.
Finance
Claims, rejections and what each company actually settles.
A portal in another tab versus eligibility in the visit
The information is available either way. The question is whether it arrives in time.
The way it is done now
- Eligibility checked when someone remembers
- Approvals chased by email
- Claims tracked in a spreadsheet
- Rejections read one at a time
- Cover discovered after treatment
With Medicolize
- Checked as part of arrival
- Raised from the visit, stored against the service
- Followed from submission to remittance
- Grouped by reason, so the cause is visible
- Cover known before the service is delivered
Questions
Saudi Arabia — what clinics ask
What is NPHIES?
It is the Saudi national platform through which providers and insurers exchange eligibility checks, pre-authorisations and claims. Working through it is how an insured visit in the Kingdom gets confirmed and paid.
Does eligibility work at the reception desk?
Yes. The check runs against the policy held on the patient record and answers at the counter, with the cover, the limit and the co-payment, before the visit is booked in.
Can we raise pre-authorisations from the visit?
Yes, with the clinical documentation attached, and the approval reference is stored against the service it covers rather than in an email folder.
How are rejections handled?
They are grouped by reason rather than listed one by one, which is what makes a recurring documentation problem visible instead of looking like bad luck.
Does this replace the insurance module?
No, it works with it. The insurance module holds each company, its price list and its approval rules; NPHIES is how the eligibility and the claim actually travel.
Keep going
Related features
Insurance
Company price lists, eligibility, approvals and claims tracked to payment. Medicolize stops insurance work being done…
Read moreBilling & accounts
Invoices that build themselves from what was delivered, with packages, insurance share and expenses in one ledger.…
Read moreSaudi Arabia
Phase two clearance as the invoice is raised: QR code, VAT breakdown, insurance share and Arabic invoices, cleared…
Read morePut Saudi Arabia in front of your own week
Half an hour on your own services, packages and price list. Someone calls you back within a day.