Roles and Stakeholders¶

Overview¶

Understanding the key stakeholders in Saudi healthcare is essential for effective system design and integration. This document outlines the primary roles, responsibilities, and interactions within the ecosystem.

Healthcare Providers¶

Hospitals¶

Types: - MOH Hospitals - Private Hospitals - University Hospitals - Military Hospitals

Key Departments: - Patient Access/Registration - Health Information Management (HIM) - Revenue Cycle Management (RCM) - Clinical Departments - IT/Digital Health

Key Roles:

Role	Responsibilities
HIM Director	Coding oversight, compliance
RCM Manager	Claims, denials, collections
Coders	ICD-10/CPT assignment
Billers	Claim submission
AR Specialists	Follow-up, appeals

Primary Care Centers¶

First point of contact
Referral management
Chronic disease management
Preventive care

Insurance Organizations¶

Insurance Companies¶

Major Payers: - Bupa Arabia - Tawuniya - Medgulf - AXA Cooperative - Malath Insurance

Departments: - Provider Relations - Medical Management - Claims Adjudication - Appeals - Fraud Investigation

Third-Party Administrators (TPAs)¶

Key TPAs: - GlobeMed - NextCare - Mednet

Services: - Claims processing - Provider network management - Prior authorization - Care coordination

Regulatory Bodies¶

Ministry of Health (MOH)¶

Responsibilities: - Healthcare policy - Provider licensing - NPHIES oversight - Quality standards

CCHI (Council of Cooperative Health Insurance)¶

Responsibilities: - Insurance regulation - Unified policy standards - Consumer protection - Market oversight

Saudi FDA (SFDA)¶

Responsibilities: - Drug approvals - Medical device regulation - Food safety - Pharmaceutical pricing

National Health Platforms¶

NPHIES Administration¶

Key Functions: - Platform operations - Provider support - Standard development - Integration testing

Seha Virtual Hospital¶

Services: - Telemedicine - Remote consultations - Specialist access

Technology Partners¶

System Integrators¶

EMR/EHR vendors
Revenue cycle systems
Integration platforms

Solution Providers¶

AI/ML companies
Analytics platforms
Security vendors

BrainSAIT Role¶

Position: Healthcare AI Platform Provider

Value Proposition: - AI-powered claims processing - Intelligent document processing - Policy compliance automation - Diagnostic imaging support

Patient Stakeholders¶

Patients¶

Interactions: - Registration - Eligibility verification - Consent management - Bill payment

Employers¶

Responsibilities: - Employee coverage - Premium payments - Dependent management

Stakeholder Interactions¶

Claims Flow¶

graph LR
    A[Patient] --> B[Provider]
    B --> C[NPHIES]
    C --> D[Payer/TPA]
    D --> E[Adjudication]
    E --> F[Payment]
    F --> B

Authorization Flow¶

graph LR
    A[Provider] --> B[Auth Request]
    B --> C[NPHIES]
    C --> D[Payer Review]
    D --> E[Approval/Denial]
    E --> A

Communication Channels¶

Provider to Payer¶

NPHIES portal
Provider relations
Appeals process
Contracts/negotiations

Provider to Patient¶

Registration
Consent forms
Financial counseling
Billing statements

Regulatory Communication¶

MOH circulars
CCHI bulletins
NPHIES updates
Compliance notices

Key Success Factors¶

For Providers¶

Strong RCM team
Accurate coding
Timely submission
Proactive denial management
Technology adoption

For Payers¶

Efficient adjudication
Fair reimbursement
Provider support
Fraud prevention
Member satisfaction

For Regulators¶

Clear standards
Consistent enforcement
Stakeholder engagement
Technology enablement
Market stability

Last updated: January 2025