Introduction

This implementation guide provides the business and technical requirements for healthcare providers and healthcare insurers 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.
• Downloads - Allows downloading a copy of this implementation guide and other useful information