One NPHIES-native platform for revenue cycle, claims adjudication, pharmacy benefit and medical coding, built for the Kingdom.
Relied on by
Four products share one rule library and one audit trail. Here's what happens to a single patient visit, from the front desk to the payer's decision.
Step 1 of 4: the patient arrives
Registration, eligibility and billing on one engine, with no per-payer forks.
Every encounter is verified before care and released as a payer-ready bill, with AR-DRG grouping available at the point of billing.
Step 2 of 4: the notes become codes
A fine-tuned language model turns free-text diagnoses into standard and DRG codes.
AI then checks ACS coding rules, record completeness and medical necessity before the claim leaves the building. Every code traces back to the rule that produced it.
Step 3 of 4: the prescription is filled
Every drug check happens at the moment of dispensing, not months later through claw-back.
Interaction, duplication and dosage checks at entry, refill and quantity rules per CHI guidance, and formulary and tier control for payers.
Step 4 of 4: the payer decides
Most claims adjudicate themselves. Reviewers see the rest in order of recovery value.
A rule library mapped line by line to CHI policy, with fraud, waste and abuse scored at claim, provider and clinician level, and every decision logged.
The platform can reach more than 500 hospitals and 6,000 pharmacies in Saudi Arabia, and runs live across the Gulf and in the Maldives.
ERAAD+: revenue cycle management
The full revenue cycle on a single engine, from patient registration to a released, payer-ready bill.
The patient is captured once and shared downstream.
Eligibility is checked before care, not after the bill bounces.
AR-DRG grouping is available at the point of bill release.
One engine bills every payer against 12M+ edit rules.
Denials are resubmitted automatically, with root-cause coding.
One engine across every payer, with no forks and no parallel builds.
Casemix grouping available the moment a bill is released.
Automated resubmission workflows that record why each claim was denied.
Coding+: medical and DRG coding
Every code traceable to the rule that produced it.
Clinician's note, as written
Pt c/o chest pain radiating to L arm, r/o MI, ECG done…
Coded as ICD-10-AM, ACHI and AR-DRG
A fine-tuned language model turns free-text diagnoses and services into standard codes.
ACS coding rules are checked by AI against every coded line.
Medical-record completeness is confirmed before submission.
Medical necessity is established against the encounter.
Cephal PBM & eRx: e-prescription and pharmacy benefit
One engine covers prescribing and pharmacy benefit.
E-prescription readiness for hospital and retail pharmacy, with prescriber identity and controlled-drug governance.
Interaction, duplication and dosage checks, with pregnancy and age-appropriateness cautions.
15M+ drug rules applied at the point of dispensing, refill and quantity rules per CHI guidance, and formulary and tier control.
E-prescription
Built for hospital and retail pharmacy, prescribers and MoH outpatient programmes.
Pharmacy benefit management
Built for payers, TPAs, hospital pharmacy and retail chains.
360 Claims: claims adjudication
85%
of claims auto-adjudicated
Payer-side adjudication against a rule library mapped line by line to CHI policy, with reviewer queues ordered by recovery value rather than arrival.
A rule library mapped line by line to CHI policy, every rule traceable to the clause it enforces.
Every claim scored at claim, provider and clinician level.
85% of claims adjudicate themselves, and every decision is logged.
The rest go to reviewers in order of recovery value, not arrival time.
Outcome-linked commercials: savings-share models, capped per MSA.
Tertiary hospitals, private chains, polyclinics and specialty centres.
Revenue cycle, a coding pipeline and embedded grouping for casemix billing.
Products: ERAAD+ and Coding+
Riyadh
GCC
Maldives
Kuwait
Qatar
Oman
More than 50 government authorities and private companies across MENA, Asia and the Pacific.
| Saudi Arabia | KFSH&RC, CNHI, MoD multi-site and MoI Riyadh | Anchor |
|---|---|---|
| GCC | AXA | Live |
| Maldives | National reference deployment | Live |
| Oman, Kuwait, Qatar | Including Oman MoH | Pipeline |
Every claim, coding decision and refill check leaves a reproducible trail. Here is what each standard guarantees you.
| Standard | What it means for you |
|---|---|
| NPHIES | Native exchange with the Saudi national platform (FHIR R4). |
| AR-DRG | Production-grade grouping with a full, reproducible audit trail. |
| ICD-10-AM, ACHI, ACS | Coding standards built into the engine, not bolted on. |
| CCHI-BS | The Saudi Benefit Schedule wired into adjudication rules. |
| NCA and PDPL | Data residency in the Kingdom, AES-256, TLS 1.3 and tamper-evident logs. |
| ISO 9001:2015 | Quality management. |
| ISO 27001 | Information security. |
| ISO 22301 | Business continuity. |
| SOC 2 Type II | Independently audited security and privacy controls. |
Revenue cycle, claims adjudication, pharmacy benefit and medical coding, anchored in the regulatory reality of the Kingdom.
100%
NPHIES-native, from the first release.
Mandatory insurance expansion puts more people into the system.
AR-DRG at tertiary level ties payment to what was actually done.
NPHIES is now the single national exchange.
The PHAP and CNHI programmes are cleansing national data.
Claims should adjudicate themselves, records should arrive clean, and clinicians should spend their time on patients, not on billing.
Built to CHI policy, the NPHIES schema and AR-DRG version control.
Every decision logged, every outcome reproducible and defensible.
Reference data tuned to the Kingdom, not a global retrofit.
Savings-share and gain-share models, capped per MSA.
Open API, data-export guarantees and revocable licensing.
Multi-year MSAs with joint governance and co-managed incidents.
Running a payer, a tertiary hospital, a regulatory programme or a regional health reform? Pilots and procurements are both welcome.
Yes. Cephal is NPHIES-native from the first release and exchanges with the Saudi national platform over FHIR R4.
In the Kingdom. The platform follows NCA and PDPL requirements, with AES-256 and TLS 1.3 encryption and tamper-evident audit logs.
ICD-10-AM, ACHI, ACS and AR-DRG are built into the engine, and the Saudi Benefit Schedule (CCHI-BS) is wired into adjudication rules.
Yes. Pilots and procurements are both welcome. Tell us about your programme and our team will reply by email to arrange next steps.
Send RFP documents to accounts@cephalmed.com and we'll confirm receipt.
Through multi-year MSAs with joint governance and co-managed incidents. Savings-share and gain-share models are available, capped per MSA.
No. Cephal offers an open API, data-export guarantees and revocable licensing.
