Course: INT-01

Web Services Integration

Implementation Guide
Beneficiary Stakeholder | HCPs
Domain | Technical
 Agenda
Introduction Implementation Guide

Integration Courses Poll

Scope Quiz

Information Flow Feedback Form

Use Cases Q&A

Contents Web Services Integration - Implementation Guide

Introduction

Introduction Web Services Integration - Implementation Guide

 Introduction
nphies is a centralized validating standards-based information exchange gateway, which helps to connect all healthcare providers and payers within KSA. The aim is to

support the market by providing timely, efficient and cost-effective products and services to people requiring healthcare services in the kingdom of Saudi Arabia.

• Centralized – financial data exchange (eClaims transactions) between providers and payers will be facilitated by a single centralized hub.
• Validating – transactions will be validated for compliance to data formats and coding standards and monitored for compliance with regulatory requirements and
good business practice.
• Standards-based –data formats for the information exchanges are based on internationally recognized standards that are appropriately constrained to meet the
local Saudi business needs.
• Information Exchange – to facilitate the exchange of consistent and high-quality transactions between providers and payers to support the business of health
insurance.
• Gateway – to validate and deliver a transaction to the intended recipient in real-time, or store the transaction for delivery when the recipient is available, or reject
the transaction if it is invalid.

Introduction Web Services Integration - Implementation Guide

Integration Courses

Integration Courses Web Services Integration - Implementation Guide

 Technical Integration Courses
Through the course of the technical integration training, the below courses will be offered:

• INT-01*: an introductory course to the web services integration

Session I: Share the implementation guide, how to use the guide and answer any relevant questions

Session II: Share the APIs, sample messages and the detailed workflow

• INT-02: Course providing details about the nphies onboarding integration solution registration, configuring, and utilization to perform the nphies transaction

mapping and communication.

*Certification: Training attendance and completion of INT01 course is mandatory in order to receive the certification for the technical integration through nphies.

Introduction Web Services Integration - Implementation Guide

Scope

Scope Web Services Integration - Implementation Guide

 Scope

Scope Web Services Integration - Implementation Guide

Information Flow

Information Flow Web Services Integration - Implementation Guide

 Information Flow

Information Flow Web Services Integration - Implementation Guide

Use Cases

Use Cases Web Services Integration - Implementation Guide

 Use Cases
❑ Check Eligibility Cycle
❑ Process Claim Cycle
❑ Advanced Pre-authorization Cycle

❑ Request Pre-authorization Cycle

❑ Request Claim Supporting Documents
❑ Cancel Pre-authorization Service

❑ Cancel Claim Request

❑ Payment Reconciliation
❑ Payment Confirmation Notification

Use Cases Web Services Integration - Implementation Guide

 Use Case 1

Check Eligibility Cycle

This use case enables the HCPs to verify the
beneficiary’s insurance coverage benefit plans which
makes them eligible to receive healthcare services at
the given facility.

Use Case Web Services Integration - Implementation Guide

 Use Case 2

Process Claim Cycle

This use case enables the HCP to electronically
submit the health insurance claims to the HIC for
adjudication. This applies for both single and batch
of claim submission.

Use Case Web Services Integration - Implementation Guide

 Use Case 3

Advanced Pre-authorization Cycle

This use case enables HIC to send Pre-authorization
response for service(s) for a specific beneficiary in advance,
without receiving a pre-authorization request from the HCP.
This is to eliminate the waiting time for the patient at the
targeted HCP.

Use Case Web Services Integration - Implementation Guide

 Use Case 4

Request Pre-authorization Cycle

This use case enables the HCP to obtain an
approval from the HIC to receive reimbursement for
delivering the requested service/ treatment to the
beneficiary.

Use Case Web Services Integration - Implementation Guide

 Use Case 5

Request Claim Supporting Documents

This use case enables the HICs to request
supporting document(s) for a specified transaction to
support business processes such as adjudication.

Use Case Web Services Integration - Implementation Guide

 Use Case 6

Cancel Pre-authorization Service

This use case enables the HCP to send cancel Pre-
authorization to HIC

Use Case Web Services Integration - Implementation Guide

 Use Case 7

Cancel Claim Request

This use case enables HCP to send Nullify/ Cancel
Claim Request to HIC.

Use Case Web Services Integration - Implementation Guide

 Use Case 8

Payment Reconciliation
This use case enables HIC to send the payment
advice (Payment Reconciliation) to the HCP.

Use Case Web Services Integration - Implementation Guide

 Use Case 9

Payment Confirmation Notification

• This use case enables HCP to send the

payment confirmation to the NPHIES

• Payment Confirmation Notification

Service will have the ability to link to an
existing payment advice notification

Use Case Web Services Integration - Implementation Guide

Implementation Guide

Implementation Guide Web Services Integration - Implementation Guide

 Implementation Guide
Objective of the Implementation Guide:

to enable external payors and providers to integrate with NPHIES

The guide covers:

Information exchange construction and flow between different healthcare stakeholders and the solution

Use Cases

Defines the message structure of profiles for FHIR implementation

Specifies the links to relevant FHIR artifacts and documentation

Where to find the Implementation Guide:

Will be shared via email after the training session
available under “technical Standards” on CCHI website at the following link: https://www.cchi.gov.sa/en/Uniplat/Pages/default.aspx

Implementation Guide Web Services Integration - Implementation Guide

Poll

Poll Web Services Integration - Implementation Guide

 Poll

Please submit your answers to the below questions from your devices, answers will be captured in real time and will help us assess your level of readiness to integrate.

Poll Web Services Integration - Implementation Guide

Quiz
Feedback Form

Quiz & Feedback Form Web Services Integration - Implementation Guide

 Quiz & Feedback Form
Quiz:

To assess your knowledge of the materials shared during this session

To help close gap on the next training session

Feedback Form “ feedback form will pop up at the end of the session after Q&As”

To help us improve our training sessions

Close any gaps

Manage future training sessions

Quiz & Feedback Form Web Services Integration - Implementation Guide

Q&A

Quiz & Feedback Form Web Services Integration - Implementation Guide

Thank You
Contact Channels

Onboarding Contact Center:

920004299

Onboarding Email
onboarding@cchi.gov.sa