Payer Integrations¶

Overview¶

This document provides detailed integration specifications for major Saudi payers. Understanding payer-specific requirements is essential for maximizing claim acceptance rates and minimizing denials.

Integration Architecture¶

graph TB
    subgraph "BrainSAIT Platform"
        A[ClaimLinc]
        B[Payer Router]
    end

    subgraph "NPHIES"
        C[Central Gateway]
    end

    subgraph "Payers"
        D[Bupa Arabia]
        E[Tawuniya]
        F[GlobeMed]
        G[Medgulf]
    end

    A --> B
    B --> C
    C --> D
    C --> E
    C --> F
    C --> G

Bupa Arabia¶

Overview¶

• Market Share: ~25%
• Type: Full-service insurer
• Specialty: Comprehensive health coverage

Integration Details¶

Submission Requirements¶

Authorization: - Prior auth mandatory for inpatient - Pre-certification for procedures > 5,000 SAR - Real-time auth for emergencies

Documentation: - Complete clinical notes - Discharge summary (inpatient) - Lab/radiology reports - Care plan (chronic)

Coding: - ICD-10-AM primary and secondary - ACHI for procedures - CPT for professional services

Timely Filing¶

• Standard claims: 180 days
• Retroactive auth: 72 hours
• Appeals: 60 days

Common Rejection Reasons¶

1. Missing prior authorization
2. Incomplete clinical documentation
3. Out-of-network provider
4. Benefit exclusion
5. Coding errors

Best Practices¶

• Verify network status before service
• Obtain auth for all planned admissions
• Include detailed clinical notes
• Use approved formulary medications
• Submit within 30 days of service

Tawuniya¶

Overview¶

• Market Share: ~20%
• Type: Full-service insurer
• Specialty: Corporate and individual plans

Integration Details¶

Submission Requirements¶

Authorization: - Elective inpatient: 48 hours advance - Day surgery: 24 hours advance - High-cost procedures: Pre-approval required

Documentation: - Itemized bill - Clinical justification - Operative notes (surgical) - Pathology reports

Coding: - Focus on accurate primary diagnosis - Modifier requirements strict - Package pricing for common procedures

Timely Filing¶

• Standard claims: 180 days
• Corrections: 90 days
• Appeals: 45 days

Common Rejection Reasons¶

1. Incorrect package code
2. Timely filing exceeded
3. Coding inconsistencies
4. Missing modifier
5. Benefit limit exceeded

Best Practices¶

• Use package codes when available
• Submit claims within 2 weeks
• Verify benefit limits
• Include all relevant diagnoses
• Double-check modifiers

GlobeMed¶

Overview¶

• Market Share: ~12%
• Type: Third-Party Administrator (TPA)
• Specialty: Claims management

Integration Details¶

Submission Requirements¶

Authorization: - All inpatient requires pre-cert - Specialist referral documentation - Utilization review compliance

Documentation: - GlobeMed-specific forms - UR approval reference - Detailed clinical reports - Referral letters

Coding: - Strict code validation - Clinical-to-code alignment - Justification required

Timely Filing¶

• Standard claims: 90 days
• Corrections: 60 days
• Appeals: 30 days

Common Rejection Reasons¶

1. Missing UR approval
2. Incomplete TPA forms
3. No specialist referral
4. Clinical documentation gaps
5. Code-to-diagnosis mismatch

Best Practices¶

• Complete GlobeMed forms accurately
• Obtain UR approval before service
• Include referral documentation
• Detailed procedure notes
• Timely submission critical

Medgulf¶

Overview¶

• Market Share: ~15%
• Type: Full-service insurer
• Specialty: Corporate plans

Integration Details¶

Submission Requirements¶

Authorization: - Standard prior auth rules - Emergency retrospective (48 hours) - High-cost threshold: 10,000 SAR

Documentation: - Standard clinical documentation - Operative reports - Itemized charges

Coding: - Standard ICD-10/CPT - Careful with unbundling

Timely Filing¶

• Standard claims: 120 days
• Corrections: 60 days
• Appeals: 45 days

Common Rejection Reasons¶

1. Late submission
2. Missing authorization
3. Unbundling issues
4. Benefit exclusions
5. Non-covered services

Best Practices¶

• Note shorter filing deadline
• Verify coverage before service
• Check bundling rules
• Include complete charges
• Detailed operative notes

Payer Comparison Matrix¶

ClaimLinc Payer Optimization¶

BrainSAIT's ClaimLinc agent automatically:

1. Routes claims to correct payer
2. Applies payer rules during validation
3. Optimizes coding for payer preferences
4. Generates documentation per payer requirements
5. Tracks payer-specific KPIs

Related Documents¶

• Claim Lifecycle
• Rejection Types
• Resubmission Playbook
• ClaimLinc Agent

Last updated: January 2025