Payer Intelligence Engine

What We Need to Get Started

Minimum data requirements based on CCHI Minimum Data Set (MDS) standards

1

Minimum Data Required

1 Month History Recommended

Patient Information

✓
Unique Member ID
National ID / Iqama / Resident ID
✓
Patient Age & Gender
Date of birth or age at service
✓
Policy Number
Insurance policy / card number
✓
Insurer Name
Payer / insurance company

Clinical Information

✓
ICD-10-AM Diagnosis Codes
Primary + secondary diagnoses
✓
Procedure Codes
ACHI / CPT codes
✓
Date of Service
Service / admission / discharge dates
✓
Encounter Type
IP / OP / ED / Day Case
✓
Provider Specialty
Treating physician's specialty
✓
Facility ID
CCHI licensed facility identifier

Billing Information

✓
Billed Amount (SAR)
Total charge submitted
✓
Authorization Number
If pre-auth was obtained
✓
Date of Submission
When claim was filed
✓
Claim Status
Approved / Denied / Pending
✓
Denial Reason Code
NPHIES denial code (if denied)

2

Integration Options

Quick Start Tier 1

CSV Upload

Export claims from your billing system, upload a CSV file, and get results in minutes.

✓ No IT integration needed
✓ Results in under 5 minutes
✓ Batch analysis of 10,000+ claims
✓ Excel/CSV export of results

Setup time: Same day

Recommended Tier 2

API Integration

REST API connects to your EMR or billing system for real-time claim checking before submission.

✓ Real-time pre-submission check
✓ RESTful JSON API
✓ <200ms response time
✓ Webhooks for async results
✓ SDKs for common EMR platforms

Setup time: 1–2 weeks

Enterprise Tier 3

Full NPHIES Integration

Direct integration with NPHIES platform for automated pre-submission validation.

✓ NPHIES FHIR R4 native
✓ Automatic pre-auth requests
✓ Real-time eligibility checks
✓ Claim status tracking
✓ Full audit trail

Setup time: 3–4 weeks

3

Implementation Timeline

1

Week 1

Data Upload

Upload historical claims data. System configuration and payer mapping.

2

Week 2

Model Training

Custom ML model trained on your hospital's claim patterns and payer mix.

3

Week 3

Testing & Validation

Side-by-side testing with your billing team. Accuracy validation.

4

Week 4

Go Live

Real-time claim checking enabled. Staff training and support begins.

4

Data Security & Compliance

PDPL 2023

Saudi Personal Data Protection Law compliant

Data in KSA

All data stays within Saudi Arabia

Encryption

AES-256 at rest & TLS 1.3 in transit

No Sharing

Zero data sharing between hospitals