المملكة: Including emergency care and transparency… 16 commitments of private health institutions

In its decision, the Council stressed that the provision of emergency health care will not be linked to obtaining prior approval, while emphasizing that health care providers bear full responsibility for the final medical decisions related to the care provided to beneficiaries, ensuring rapid response to emergency and critical cases and protecting the lives of beneficiaries.

Developing a comprehensive framework

The mechanism aims to develop a comprehensive framework that defines the relationship between the National Health Insurance Center and private health institutions within the Kingdom, with a focus on ensuring quality and efficiency. Health services provided to all beneficiaries.

The mechanism seeks to enhance transparency in dealing between beneficiaries and health institutions, unify mechanisms for submitting and processing claims, and manage the relationship in an organized and effective manner.

It also includes organizing communication and electronic linking procedures to ensure rapid response to complaints and objections, with a focus on protecting the rights of beneficiaries and facilitating their access to health care without any administrative obstacles, which reflects the commitment to providing high-level health services that are compatible with international best practices

Institutions Private health care in Saudi Arabia

The provisions of this mechanism apply to several cases related to the Center’s relationship with private health institutions within the Kingdom. These cases include the Center’s dealings with those institutions when purchasing emergency and ambulatory care services, in accordance with the beneficiaries’ medical and demographic eligibility criteria, to ensure the provision of appropriate care at the right time.

It includes dealing with private health institutions in cases of medical referrals through the unified referral system, in accordance with the policies for referring critically ill, life-saving and emergency patients to and from private hospitals, taking into account any Regulations or amendments that may be issued later.

The mechanism also includes any entity or third party – a subcontractor – who is authorized in writing by the accredited health institutions after the Center’s approval, to implement part of the obligations stipulated in this mechanism or in the agreements concluded between the Center and health care providers.

National Health Insurance Center

The National Health Insurance Center is committed to preparing clear and unified agreements with private health institutions, aiming to regulate the relationship between the two parties in an accurate and orderly manner.

These agreements include Defining dealing mechanisms and the level of service, including key performance indicators and health care quality standards, protecting against risks, and ensuring fair distribution of services to beneficiaries.

The agreements include allocating a dedicated electronic portal to receive claims and invoices and respond to inquiries within specific time frames, in addition to setting a clear mechanism for settling claims once documents are completed via the electronic platform.

Protecting the rights of beneficiaries

The agreements also include a mechanism to address grievances and objections submitted by health care providers in the event Rejecting financial claims, which reflects the Center’s commitment to transparency and efficiency in managing the relationship with health institutions and protecting the rights of beneficiaries.

The mechanism obligated the accredited private health institutions to adhere to the unified agreement, which includes a set of basic standards and obligations to ensure the provision of high-quality health care and protect the rights of beneficiaries.

Best Medical Practices

These obligations include providing health care with the highest levels of professionalism and ethics in accordance with the best medical practices, without any discrimination between beneficiaries, and refraining from requesting or receiving any direct payments from them for the services provided.

The mechanism emphasized the necessity of providing emergency care without linking it to obtaining prior approvals, while holding caregivers fully responsible for final medical decisions, including the quality and appropriateness of care, and adherence to medical protocols and standards issued by the competent authorities.

The agreement prohibits offering any financial incentives related to referring patients to other institutions or departments, and emphasizes continuous review and evaluation of services, and taking corrective measures based on results, observations, and complaints to ensure continuous improvement.

Verifying the identity of the beneficiary

The obligations include verifying the identity and eligibility of the beneficiary before submitting claims, and informing the claims management company within three hours of receiving emergency cases and a maximum of 24 hours, otherwise the care provider will bear the cost of the services provided, in addition to issuing and renewing all licenses and registration documents necessary to provide services and delivering copies of them to the center.

The mechanism obliges institutions to enable the center or its delegate to access the information, documents, and places necessary to evaluate claims and verify that the conditions for providing services are met. Responding to inquiries and requests from the Center and the Claims Management Company within 60 minutes of receipt and a maximum of 24 hours, and submitting the required reports according to the mechanism and the period specified by the Center.

The obligations also include cooperation with the Center and the Claims Management Company in the event of transferring beneficiaries, and refraining from any actions that may involve misuse or fraud, with a commitment to sharing the minimum amount of data with the Center in accordance with the regulations, decisions and agreements concluded, which reflects the mechanism’s keenness to regulate the relationship between health care providers and the Center and ensure the protection of beneficiaries and their rights.