CHI Claims Procedures in KSA
Transport & Logistics Focus
Ahmed HashemSenior Counsel,Transport & Insurance
Jamal NattoAssociate,Transport & Insurance
Health insurance is becoming a priority topic around the world, and governmental bodies are keen to regulate this matter and control over the respective bodies in the health insurance market. In the Kingdom of Saudi Arabia “KSA” the Council of Health Insurance “CHI” is the controlling authority that regulate the rights and responsibilities between the Policyholder, the Insurance Companies, Third-Party Administrator “TPA” and the Health Service Provider, all referred to as “Insurance Parties” where their legal rights and obligations are outlined in the Implementing Regulations of the Cooperative Health Insurance Law “Implementing Regulation”. Throughout this article, we will provide a brief overview of the roles and responsibilities of the Insurance Parties, as well as the different types of claims that may arise between them.
The CHI was established to fulfil its purposes by ensuring that the beneficiaries receive the appropriate basic health insurance coverage, such as medical examination, outpatient treatment and medications according to the minimum coverage set out in the Cooperative Health Insurance Policy. In addition, the CHI are intended to accredit both Insurance Companies and TPAs to work in the Health Sector by adhering to the specifications listed on their website. It is however necessary for the previous entities to obtain licenses from the Saudi Central Bank "SAMA" before they can conduct insurance or insurance services activities.
patient (Policyholder) visits a health care facility (Health Service Provider) in order to obtain medical care, the process usually begins. Once the medical service is performed, the Health Service Provider will submit these insurance claims to the TPA within a legal timeframe. The TPA then examines these insurance claims and decides whether to accept or reject them, and then resubmits them to the Health Service Provider in order to comply with the requirements. Once these requirements are met, the claim will be submitted to the Insurance Company for payment. This information is exchanged through the official KSA platform called “NPHIES” which is a specialised platform related to Health and Insurance exchange services established by both the CHI and the National Centre for Health Information “NHIC”.
The CHI has issued the Unified Contract between Insurance Companies and Health Service Provider in the private sector.
Given the importance and complexity of the commercial and legal relationship between the Insurance Companies and the Health Service Providers, the CHI has issued the Unified Contract between Insurance Companies and Health Service Provider in the private sector “Unified Contract”. A number of different aspects are governed by these agreements, such as technical and financial obligations and beneficiary rights, dispute resolution, etc.
Legal violations are outlined in the CHI Implementing Regulations for the Insurance Parties, and any related person may utilize their legal rights to file a complaint with CHI against those Insurance Parties who are in violation of the CHI Implementing Regulations. Given that the most common violation is the failure of the Insurance Companies to settle the due amounts to the Health Service Provider within the legal timeframe, for example.
In this case, the Health Service Provider may file a CHI complaint against the Insurance Company by applying through the CHI portal. However, a conciliation request must be submitted beforehand to the official conciliation platform in the KSA called “Taradhi”, it acts as a general conciliation platform that contain several conciliation centres such as the “CHI Reconciliation Centre”.
In accordance with the Unified Contract, any disputes between the Health Service Provider and the Insurance Companies will be referred first to the CHI Reconciliation Centre, and should a settlement not be reached, the parties may refer the dispute to the competent judicial authority. Therefore, the relative party must submit a conciliation request first before the Taradhi platform before commencing any other legal action.
In practice and depending on the case merits it is recommended for the Health Service Provider to first send a legal notice against the Insurance Company, given that most Health Service Provider gain their income from the Insurance Companies. Therefore, it is wise to exhaust all amicable options before taking any legal action against them.
Upon submitting of the of the conciliation request in the Taradhi platform, the Health Service Provider must ensure collecting of the sufficient documentations that support the claim amount, otherwise the application will be rejected. However, if the application got accepted, the conciliator will hold approximately one to two sessions until the final report is issued. Usually, the conciliation application does not succeed but it is a legal perquisite that must be met before escalating the dispute to the competent judicial authority.
Upon issuance of the conciliation report, the Health Service Provider have either two options that either to submit a complaint in the CHI platform or file a lawsuit before the General Secretariat of the Committees for Resolution of Insurance Dispute & Violations “Insurance Committees”.
The CHI complaint is constructed under the violations mentioned in the CHI Implementing Regulation, and once the complaint is submitted it will be referred to the Cooperative Health Insurance Law Provisions Violations Consideration Committee’s Regulation “CHI Committees” that is concerned about receiving of complaints by the respective parties. The CHI as a controlling authority will conduct its investigations and depending on the case will contact both the claimant and the defendant independently and they have the right to request for information and submitting of documentations, until the issuance of an official decision. The decision may be challenged by submitting an appeal before the component Administrative Court.
Additionally, Health Service Providers may file a lawsuit against the Insurance Companies before the Insurance Committee as one of their legal options. Healthcare invoices, monthly signed conciliations, proof that the TPA has accepted or rejected the submitted claims must all be maintained throughout the life cycle of the Unified Contract. When the aforementioned documents are provided, the chances of the claimant obtaining a favorable decision before the Insurance Committee will increase.
Consequently, it is always recommended that the Insurance Parties maintain an organized record of all relevant documentation, requesting the TPA to sign for a timely conciliation separately for each entity within the Health Service Provider group. Lastly, compliance with all CHI regulations as well as other relevant regulations is imperative to ensure that the CHI regulations and other related regulations are fulfilled for the benefit of the health insurance industry and its stakeholders.
For further information,please contact Ahmed Hashem or Jamal Natto
Published in August 2023
