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Clinic › Settings › NPHIES · the patient's file · the visitWho
The connection: people with Clinic Settings — NPHIES connection (the top role). An insurer's payer licence: people who may edit the clinic's settings. Checking, prior authorization and sending claims: people who may move claims.Set up the clinic
1
In Clinic › Settings, in the NPHIES card, type the Provider licence, the Facility licence and the Provider type from the clinic's NPHIES licence, choose Sandbox (test) or Production, and type the NPHIES address you were given. Paste the Certificate and the Private key NPHIES issued (and their passphrase, user name and password if you were given them). They are kept sealed and never shown again; the card only says whether each is set.
2
Press Save the NPHIES settings, then Turn NPHIES on. Only a company whose address is in Saudi Arabia can turn it on. Off, nothing is sent to NPHIES and the clinic's claims are kept by hand, exactly as before.
3
In the same card, give each service its NPHIES code and its code list, each doctor their Practitioner licence and speciality code, and each insurer on NPHIES its Payer licence. An insurer without a payer licence is kept by hand.
The patient
4
On the patient's file, in the NPHIES card, type the Member ID from the insurance card and choose the kind of ID (national ID, iqama or passport); the number itself is the file's national ID. The patient's plan is the one on their file.
5
Press Check eligibility — on the file, or on the visit when the patient arrives. The answer is kept on the file: Covered or Not covered, NPHIES's own words, and each benefit with what is allowed and what is used.
The visit
6
When the insurer asks for it, press Ask for prior authorization on the visit's NPHIES card. The visit's procedures are sent with their codes and the diagnosis code. The answer is kept: approved, partly approved (with what was approved), denied (with NPHIES's reasons) or pending, with its reference. An approved reference goes with the claim.
7
Open the visit's insurance claim as usual, then press Send the claim to NPHIES. The claim's steps follow NPHIES's answer: Approved, Approved with changes (the amounts NPHIES approved are shown, and the insurer's and patient's invoices are split by them), Rejected (with NPHIES's reasons — correct the visit and send it again) or Under review. A claim NPHIES answers later says Waiting for the answer.
8
Press Ask NPHIES for answers to read what NPHIES answered since: later claim answers, and the insurer's payments. A payment is kept on the claim (amount, day and reference); once the insurer's invoice owes nothing, the claim is marked Paid.
Something missing — a member ID, the diagnosis code, a service's NPHIES code or the doctor's licence — is said by name before anything is sent. If NPHIES cannot be reached or does not take the message, the claim is not moved; the message and what NPHIES said are kept, and you can send it again.
Questions
Where is “NPHIES (Saudi health insurance)” in Zyntra OS?
Clinic › Settings › NPHIES · the patient's file · the visit
Who can use “NPHIES (Saudi health insurance)”?
The connection: people with Clinic Settings — NPHIES connection (the top role). An insurer's payer licence: people who may edit the clinic's settings. Checking, prior authorization and sending claims: people who may move claims.