A decision service that identifies the liable insurance entity for a medical case in the Kingdom of Saudi Arabia — across CCHI, NPHIES, GOSI, MoH, military health systems, Aramco, Najm/MTPL, and a fragmented landscape of private TPAs.
KSA has no general Coordination of Benefits cascade for cooperative health insurance. CHI, NPHIES, and the Insurance Authority all assume single-source coverage per beneficiary. One narrow exception surfaced in the second-pass extraction: CCHI Visitor Insurance Article 6 establishes a pay-and-subrogate model — the only explicit COB clause in any KSA primary cooperative-insurance regulation. The general regime still requires composing routing from five distinct rule families — exactly what this service does.
When a beneficiary visits a hospital in KSA, the hospital typically defaults to a single insurance provider for billing. In reality, liability is fragmented — CCHI, MoH, NPHIES, GOSI, MoI, MoD, NGHA, SAMSO, Najm, and many private TPAs all have their own rules. Whose rules apply depends on the type of case, the beneficiary's class, and the circumstances of injury. We answer that question from primary regulatory sources.
Multi-coverage routing is determined by applying these in order. The first family that yields a verdict wins. Click any source pill to see the verbatim quotation and the link to the primary document.
Highest precedence. Work injury → GOSI Occupational Hazards (Social Insurance Law M/273 of 1445H, Arts. 28/30/31/32 — supersedes the older M/33 of 1421H). RTA bodily injury → MTPL of at-fault driver. The work-injury carve-out is now confirmed verbatim in CCHI EBP §3.A.7 — Q1.1 ANSWERED.
Orthogonal to all others. Hospitals must treat first regardless of nationality, employer, or insurance — verbatim from MoH Annex 66 Article 1 + Health Law M/11 §5.E. 24-hour rule located 3 May 2026: the private hospital notifies an MoH-appointed TPA (not the patient's CCHI insurer) per Annex 66 Art. 3; TPA decides between transfer to a government hospital or state-funded continuation. CCHI Urgent Circular §6 separately exempts the three urgent levels from co-payment. Annex 66 Art. 5 establishes a Saudi-CCHI-cap-exhausted cascade: when private cap exhausted, MoH bears continuation via the TPA.
NGHA, MSD, MoI Medical, SAMSO, and Royal Commission are closed-system payers — they pay only at their own facilities. An NGHA-eligible person walking into a private hospital does not get NGHA coverage applied.
CHI's Beneficiaries Policy is an anti-duplication assignment rule, not a cascade. Default: husband's employer covers children. One unified policy per employer. Resolves which insurer is responsible at all — not how two split a bill.
What's left after the above: routine encounters → primary CCHI insurer. Special-case schemes apply if active: Hajj/Umrah pilgrim, Visitor (with explicit pay-and-subrogate COB clause in Article 6 — the only published COB cascade in any KSA cooperative regulation), Domestic Worker. Otherwise the uninsured cascade from rule family 2 takes over.
NPHIES — KSA's national FHIR-based eligibility exchange — does not return a primary/secondary indicator when a patient has multiple coverages. Coverage.order is unconstrained. Hospitals and TPAs make the call ad-hoc. This service makes it consistent, auditable, and citation-backed.
The five rule families execute as a layered cascade. The first family that yields a verdict wins. Diplomatic mission staff short-circuit at the top (Vienna Convention exemption, never enter the CCHI cascade). Verbatim Annex 66 mechanics surfaced in the second-pass extraction.
Per Vienna Convention 1961 Arts. 23/33/34, diplomatic mission staff and accredited international-organisation staff are exempt from KSA mandatory CCHI. They never enter the cascade.
beneficiary.class ∈ {DIPLOMATIC_MISSION, INTL_ORGANIZATION}
→ Embassy direct / IO insurer / Self-pay
Statute makes a specific payer the sole primary, regardless of any private insurance.
case.type == work_injury AND beneficiary GOSI-registered
→ GOSI Occupational Hazards
case.type == rta AND bodily injury AND Najm report present
→ MTPL of at-fault driver (CCHI subrogation)
Treat-first obligation always applies (Annex 66 Art. 1). Within 24 hours, private hospital notifies the MoH-appointed TPA via purchasingprogram.com.sa; TPA decides between transfer or state-funded continuation.
NGHA, MSD, MoI Medical, SAMSO, RCJY pay only at their own facilities. University Medical Cities (KAUH, KSUMC, KFSHRC) are open referral receivers — multi-payer, not closed.
For routine care after the above. Husband-employer rule is interpretive (CCHI FAQ #37, not the Beneficiaries Policy itself — verified by deep-mine). Visitor Insurance Art. 6 is the only published COB pay-and-subrogate clause.
Where the research stands today: KPIs at the top, per-rule-family coverage cards in the middle (color-coded), and the five high-risk gaps still open at the bottom.
These are the gaps most likely to materially change a routing verdict. Each is documented in docs/research/second-pass-tasks.md; addressed in the regulator letters T6–T8.
Coverage.order in multi-coverage CoverageEligibilityResponse?
Direct links to the supporting documents in the repo. All are markdown — open them on GitHub or in your editor.
First-pass research complete. Researched means primary sources cited. Partial means key documents identified but not all retrieved. Pending means not yet started.
Where we are and what's next. Click any milestone to open its detailed plan.
Greenfield. No code yet — these are the locked architectural decisions.