Healthcare Revenue-Cycle Glossary for Saudi Arabia
The terms you meet in KSA medical insurance, coding and payment reform — defined without jargon.
NPHIES
The National Platform for Health Insurance Exchange Services — Saudi Arabia's national platform connecting providers, insurers and regulators for eligibility, authorization, claims and remittance.
CCHI
The Council of Cooperative Health Insurance — the Saudi regulator of cooperative health insurance.
AR-DRG
Australian Refined Diagnosis Related Groups — the case-mix classification (version 9.0 in KSA) that groups inpatient episodes for case-based payment.
ICD-10-AM
The 10th edition of the International Classification of Diseases, Australian Modification — used to code diagnoses in Saudi Arabia.
ACHI
The Australian Classification of Health Interventions — used together with ICD-10-AM to code procedures.
SBS
The Saudi Billing System — the standardized service and pricing coding used mainly for outpatient and dental services (currently v3).
DRG weight
A relative value reflecting the average resources a DRG consumes compared with other groups; it drives the payment for the episode.
Case-mix index (CMI)
The average DRG weight of a provider's cases — a measure of the overall complexity of the patients treated.
Principal diagnosis
The condition established after study to be chiefly responsible for the admission; the main driver of DRG assignment.
Secondary diagnosis
An additional condition documented during the episode; it can raise severity and move a case to a higher-weighted DRG.
Complication
A condition that arises during the episode rather than being present on admission.
Comorbidity
An existing condition that coexists with the principal diagnosis.
CC
Complication or comorbidity — a secondary diagnosis with a moderate effect on resource use.
MCC
Major complication or comorbidity — a secondary diagnosis with a high effect on resource use.
Prospective payment
A payment model in which the amount is set in advance for an episode, rather than billed per service after the fact.
Fee-for-service (FFS)
A payment model in which providers are paid for each service delivered — the model KSA is moving away from for inpatient care.
Revenue Cycle Management (RCM)
The end-to-end process from patient registration and eligibility through coding, claim submission and final payment.
Prior authorization
Approval obtained from the payer before a service or admission, without which a claim may be rejected.
Eligibility verification
Confirming a patient's active coverage and benefits before care is delivered.
Claim rejection
A claim returned before adjudication because it fails technical or data checks; it can usually be corrected and resubmitted.
Claim denial
A claim refused after adjudication on the basis of coverage, medical necessity or contract terms.
Technical rejection
A rejection caused by format, schema or data errors rather than clinical reasons.
Medical rejection
A rejection based on clinical or coverage criteria such as medical necessity or exclusions.
Remittance advice (RA)
The payer's statement explaining how a claim was adjudicated, including payment, adjustments and rejection reasons.
ERA / EOB
Electronic Remittance Advice / Explanation of Benefits — the electronic and human-readable versions of the payer's adjudication statement.
Clinical Documentation Improvement (CDI)
Programmes that improve the completeness and specificity of physician documentation so diagnoses and severity are coded accurately.
Grouper
The software that assigns a case to a DRG from its coded diagnoses and procedures.
Upcoding
Assigning a code that overstates the service or severity — a compliance risk.