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What is Nphies?

Nphies is the National Platform for Health and Insurance Exchange Services in Saudi Arabia. It enables standardized electronic information exchange between healthcare providers and insurance entities.

Overview​

Nphies supports healthcare and insurance information exchange, including:

  • Eligibility Checks - Check a patient's insurance eligibility and coverage information.
  • Pre-Authorization - Request authorization for healthcare services.

The Juleb Nphies API endpoints documented here cover patient eligibility and authorization.

Key Concepts​

👤 Patient Information​

Patient information identifies the person receiving healthcare services. It includes details such as:

  • Patient identifier and identifier type
  • Patient name and contact information
  • Gender and date of birth
  • Insurance information and coverage class

✅ Eligibility​

An eligibility check requests information about a patient's insurance eligibility.

This helps staff review coverage before proceeding with the relevant healthcare or insurance workflow.

📋 Authorization​

An authorization request provides patient and service information for review by the insurance entity.

Depending on the request, this information can include:

  • Claim type and subtype
  • Diagnoses
  • Practitioner information
  • Requested services and quantities
  • Clinical measurements
  • Encounter details
  • Vision prescription information
note

Eligibility and authorization serve different purposes. An eligibility result alone does not establish that a particular service has been authorized or that a future claim will be paid.

Juleb Integration​

Eligibility Endpoint​

The eligibility endpoint accepts customer, patient, and insurance information. Its request structure also includes a transfer flag and baby information.

  • Method: POST
  • URL: /api/v1/nphies/eligibility

Authorization Endpoint​

The authorization endpoint accepts patient information, claim details, diagnoses, services, and encounter information.

  • Method: POST
  • URL: /api/v1/nphies/authorization

Both endpoints require authentication using a Bearer token.

Typical Workflow​

Patient Registration → Eligibility Check → Review Coverage
→ Authorization Request, When Required → Review Authorization Response

1. Collect Patient Information​

Verify the patient's identity and insurance details before submitting a request.

2. Check Eligibility​

Submit an eligibility request and review the returned insurance information.

3. Prepare Authorization Information​

When authorization is required, collect the relevant diagnoses, practitioner details, services, and supporting clinical information.

4. Submit the Authorization Request​

Send the authorization request using the applicable patient and service details.

5. Review the Response​

Review the returned decision and any conditions or additional information requests before continuing the workflow.

Business Benefits​

  • Standardized Exchange: Use a consistent platform for healthcare and insurance transactions.
  • Coverage Visibility: Review eligibility information during the patient journey.
  • Structured Requests: Provide patient, diagnosis, and service information in a defined format.
  • Coordination: Support communication between healthcare providers and insurance entities.

Best Practices​

  • Verify Patient Details: Check identifiers and insurance information before submission.
  • Use Accurate Clinical Data: Ensure diagnoses and requested services reflect the patient's case.
  • Review Responses: Check returned decisions and conditions before proceeding.
  • Protect Patient Information: Limit access to authorized staff and systems.
  • Confirm Request Requirements: Follow the API's supported codes, formats, and validation rules.