Insurance Claims Submission

Claims Management

Navigation: Insurance → Claim

The Claims screen has 5 tabs:

1. Ready for Submission

Claims awaiting submission to the Health Insurance Company (HIC).

1. Search by: Patient MRN, HIC Name, Patient Name, Request Type, Date Range
2. Select a claim and click "Send"
3. A "Select Priority" popup appears:
   • Normal — Standard processing
   • Deferred — Lower priority processing
4. Optionally upload supporting documents (max 5MB)
5. Click "Send" to submit to NPHIES

2. Submitted

Claims sent but not yet processed by NPHIES/HIC. Search by: Request Number, Patient MRN, HIC Name, Pre-Auth Request ID, Claim Request ID, Date Range.

3. Approved

Claims approved by HIC. The "Generate Bill" button is available for completed authorizations.

4. Failed

Claims that failed to process. Available actions:

• View — Show Authorization Details
• Read JSON — View raw FHIR message
• JSON Viewer — Request and Response tabs
• Resend — Resubmit to NPHIES
• Offline Authorization — Manual entry with Authorization Number, Start/End Date, Reason
• Add JSON Response — Manual JSON input

5. Rejected

All rejected claims with detailed search criteria and rejection reasons.

Manual Claim

Navigation: Insurance → Manual Claim

For submitting claims manually, the form has 5 sections:

1. Basic Information — Patient, Claim Type, Sub Type, Provider, HIC Name
2. Diagnosis — Type, Onset Date
3. Supporting Information — Vitals (Weight, BP, Height, Temperature, SpO2, Respiration), General Exam, Treatment Plan, Investigation Results
4. Item Section — Item Type, Unit Price, Patient Share, HIC Share, Tax, Service Date
5. Summary — Auto-calculated totals

HIC Configuration

Navigation: Admin Console → Billing Configuration → HIC Configuration

Configure Health Insurance Companies with NPHIES ID, license number, contact information, insurance plans, and price lists.

Common questions

How do I submit an insurance claim?

Through NPHIES — move the claim from ready-for-submission to submitted, then track it to approval.

Can I track a claim's status?

Yes — you can track each claim from submission through to approval.

What is NPHIES?

Saudi Arabia's national platform for insurance eligibility and claims, which AndroHealth integrates with.