Introduction

This implementation guide provides the business and technical requirements for healthcare providers (HCPs) and healthcare insurers (HICs) participating in the exchange of eClaims information within Saudi Arabia. The guide documents a suite of messages to: support the determination of insurance (coverage) eligibility; perform and manage authorizations; submit and respond to claims for reimbursement; cancel requests; submit supporting clinical information; request deferred responses from insurers; and, provide and confirm claim payment details.

Technical Overview

The information exchanges are implemented using HL7 FHIR R4.0.1 standard.

The main sections of this IG are:

• Background - provides business context for the implementation guide, information that implementers should be familiar with before reading the remainder of the IG, and acknowledges key contributors to the guide.
• Specification - The information exchange patterns, implementation requirements and general conformance.
• Use Cases - The use case descriptions, information flows, technical requirements and guidance.
• Artifacts - The detailed definitions of the profiles, extension, terminology and both resource and full message examples.
• Roadmap - Provides some issues or features which are not being addressed in this version of the specification but may result in changes in a future version.
• Support - Allows downloading a copy of this implementation guide and other useful implementation information