The Council of Cooperative Health Insurance (CCHI) is the Saudi Arabian government body established by Royal Decree No. M/10 in 1420H (1999 CE) to regulate and supervise the mandatory cooperative health insurance system across the Kingdom of Saudi Arabia. CCHI operates under the oversight of the Council of Ministers and functions as the primary regulator for all private health insurance activity in KSA.
CCHI's mandate covers three stakeholder groups: it licenses and supervises health insurance companies operating in KSA, enforces employer obligations to provide health coverage, and sets the standards that healthcare providers must meet to participate in the insurance reimbursement system. For any private clinic, hospital, or diagnostic centre operating in KSA that treats insured patients, CCHI compliance is a daily operational reality — not a periodic administrative task.
The CCHI Unified Medical Record system, electronic pre-authorisation requirements, and ICD-10/CPT billing mandates directly determine how clinical and administrative workflows are structured in any KSA healthcare facility. Software that is not built around these requirements creates manual workarounds, billing errors, and revenue leakage.
Understanding the scope of mandatory coverage is essential for determining which patients your facility treats on insurance and which are self-pay.
All private sector employees working in Saudi Arabia — regardless of nationality — must be provided health insurance by their employer under CCHI regulations. This coverage extends to the employee's spouse and up to three dependent children (coverage for additional dependants is at the employer's discretion or as mandated for specific visa categories). The employer bears 100% of the premium cost for the employee; dependent coverage may be split based on the employment contract.
CCHI's mandatory insurance rollout was implemented in phases: large companies (over 500 employees) from 2006, medium companies (100–499 employees) from 2008, small companies (10–99 employees) from 2009–2010, and micro employers (1–9 employees) from 2016 onwards. Today, all private sector employers regardless of size must provide CCHI-regulated coverage.
CCHI defines minimum benefit levels — the Essential Benefits Plan (EBP) — which covers essential primary and secondary care including emergency services, maternity care, chronic disease management, and medications on the approved drug list. Employers may enhance coverage beyond the EBP minimum. Premium packages from major insurers include inpatient, outpatient, dental, and optical add-ons above the EBP floor.
CCHI regulations also require health insurance for domestic workers (housemaids, drivers, etc.) under a specific domestic worker insurance programme with its own approved benefit structure and premium rates. Facilities treating domestic worker patients process claims under the applicable domestic worker insurance policy rather than the standard EBP framework.
Only CCHI-licensed insurance companies may offer health insurance products to private sector employers in KSA. The following are the major CCHI-approved health insurers, each with their own pre-authorisation portals, claim formats, and adjudication timelines.
One of the largest health insurers in KSA by covered lives, Bupa Arabia operates the Bupa Arabia provider portal for pre-authorisation requests and claim submissions. Known for relatively fast pre-auth turnaround (2–4 hours for standard requests). Covers a large share of corporate accounts in Riyadh, Jeddah, and Dammam.
Saudi Arabia's first and largest cooperative insurance company by total premiums. Tawuniya's health division covers a significant portion of the private sector market. Pre-authorisation is processed through Tawuniya's Shifa provider portal. Standard pre-auth decisions within 4–8 hours for elective procedures.
Medgulf covers a broad range of corporate clients across the Kingdom with particularly strong presence in the Eastern Province. Claim submission via the Medgulf provider portal with electronic adjudication. Standard claims processed within 30 days of receipt.
AXA operates in KSA under the cooperative insurance model and is known for serving large multinational employer clients. Pre-authorisation and claim submission via the AXA Gulf provider platform, which also serves UAE and other GCC markets. Shared platform familiarity is an advantage for facilities operating across GCC borders.
UCA focuses primarily on SME employer segments across KSA. Pre-auth and claims processed through UCA's dedicated provider portal. Turnaround times vary by benefit tier — standard pre-auth within 24 hours for non-urgent elective procedures.
Covers both individual and group health insurance plans across KSA. Al Sagr processes pre-authorisation requests through its health operations division with standard 4-hour turnaround for urgent cases and 24–48 hours for routine elective procedures.
Saudi Enaya focuses on health insurance products for mid-market employers. Electronic claim submission with 30-day payment cycle for clean claims. Pre-authorisation via Enaya's provider web portal.
Other CCHI-approved health insurers operating in KSA include: Amana Insurance, Arabia Insurance Cooperative, Walaa Cooperative Insurance, Gulf Union Cooperative Insurance, and Buruj Cooperative Insurance. The full current list of CCHI-approved insurers is maintained on the CCHI portal at cchi.gov.sa.
Pre-authorisation (prior approval) is required for a defined list of services before treatment can be provided to an insured patient. Providing services that require pre-auth without obtaining approval is the most common cause of CCHI claim rejection in Saudi Arabia.
CCHI regulations require insurers to process pre-authorisation requests within defined time limits: emergency pre-auth — within 1 hour; urgent pre-auth (medically necessary within 48 hours) — within 4 hours; standard pre-auth (elective procedures) — within 24–72 hours depending on the insurer and procedure complexity. Your HMS should track pre-auth submission timestamps and alert staff when insurer response is overdue.
Claims submitted to CCHI-regulated insurers in Saudi Arabia must comply with a defined coding and documentation standard. Understanding these requirements is essential for maximising clean-claim submission rates and minimising revenue cycle delays.
All diagnoses must be coded to ICD-10-CM (Clinical Modification), the same standard used in the United States and the UAE. Principal diagnosis should be the condition that is primarily responsible for the visit. Secondary diagnoses (comorbidities) should be coded to the highest level of specificity. Unspecified codes are permissible only when more specific information is genuinely not available — overuse of unspecified codes is flagged during insurer audits.
Procedures must be coded using Current Procedural Terminology (CPT) codes published by the American Medical Association. Each procedure performed must have a corresponding CPT code. Evaluation and Management (E/M) CPT codes (99201–99499) apply to outpatient consultations; surgical CPT codes (10000–69999) apply to surgical procedures. Unbundling — billing separately for components of a procedure that CPT bundles together — is a major audit trigger.
All CCHI claims must be submitted electronically through the insurer's approved portal or via the CCHI national electronic submission gateway. Paper claim submission is no longer accepted by most major insurers. Electronic claims are processed faster (typically 15–30 days for clean claims vs 45–60 days for paper) and provide immediate acknowledgement and tracking. Your HMS must be capable of generating CCHI-compliant electronic claim files in the required format (typically HL7 or proprietary XML) for each insurer.
Most CCHI-regulated insurers require claim submission within 90 days of the service date. Some insurer contracts specify shorter windows (30 or 60 days). Claims submitted outside this window are typically rejected as untimely, with no right of appeal. Your HMS billing module must track service dates and alert billing staff to outstanding claims approaching the submission deadline.
Understanding the most frequent causes of CCHI claim rejection allows facilities to design workflows that prevent these errors at the point of care, not at the billing stage.
Saudi Arabia introduced Value Added Tax at 15% in 2018 (initially 5%, raised to 15% in July 2020). Healthcare invoicing in KSA requires careful VAT categorisation.
In Saudi Arabia, the General Authority of Zakat and Tax (GAZT, now ZATCA — Zakat, Tax and Customs Authority) has clarified that preventive and treatment healthcare services provided by licensed healthcare providers are exempt from VAT (not zero-rated — exempt, meaning no input VAT recovery on related purchases). Medicines and medical equipment are zero-rated. Cosmetic and elective aesthetic procedures that are not medically necessary are generally subject to 15% VAT. Insurance companies pay claims exclusive of VAT on exempt services. Your billing software must be configured to correctly categorise each service line for accurate ZATCA compliance.
A hospital management system designed for the Saudi market should handle the following CCHI compliance requirements automatically, without manual workarounds.
CCHI (Council of Cooperative Health Insurance) is the Saudi Arabian regulatory authority established by Royal Decree in 1999 to regulate the mandatory cooperative health insurance system for private sector workers in KSA. CCHI licenses insurance companies, enforces employer coverage obligations, sets minimum benefit standards (the Essential Benefits Plan), and monitors compliance across the health insurance ecosystem including the providers who treat insured patients.
Yes. Health insurance is mandatory for all private sector employees and their dependants in Saudi Arabia under CCHI's Cooperative Health Insurance Law. Employers are legally obligated to provide CCHI-approved coverage and are liable for penalties — including fines and inability to renew employee visas — if they fail to do so. Saudi government sector employees are covered by the Ministry of Health network and are outside the CCHI mandatory framework.
CCHI billing requires ICD-10-CM diagnosis coding to the highest applicable specificity, CPT procedure coding, electronic claim submission within the insurer's timely filing window (typically 90 days), valid pre-authorisation reference numbers for all services that require prior approval, complete patient identification (insurance ID, Iqama number or Saudi national ID), and supporting clinical documentation for high-cost claims. ZATCA VAT rules apply for correctly categorising services as exempt, zero-rated, or standard-rated at 15%.
Claims are submitted electronically through each insurer's approved provider portal or through the national CCHI electronic submission gateway. The claim package includes the electronic claim file (containing ICD-10 codes, CPT codes, patient identifiers, pre-auth reference, and charge data) plus any required clinical documentation attachments. A CCHI-ready HMS generates the complete claim package automatically and submits it electronically, then tracks the status — acknowledged, approved, pending, or rejected — within the system's revenue cycle module.
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