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Grand total
SAR 27,600.00
Quantity times unit price
Payer Share (SAR)
22,080.00
80%
Patient Share (SAR)
5,520.00
20%
Care team
3
Primary: Dr. Faisal Al Otaibi
Prior authorization setup
- Claim Type
- Professional
- Sub-Type
- Inpatient
- Priority
- Normal
- Service Date
- 14 Oct 2026
- Authorization type
- Prior authorization
Patient identity
- Patient Name
- Noura Al Harbi
- ID Number
- 1087654321
- Date of Birth
- 17 Apr 1991
- Gender
- Female
Insurance and coverage
- Payer ID
- 7000911508
- Insurance Company
- Bupa Arabia
- Member Card No.
- 4410 2287 6035
- Policy Number
- BP-77120934
- Coverage Type
- EHCPOL
- Facility Name
- Al Raneem Hospital
- Facility Type
- HOSP
Clinical context
- Encounter Start
- 14 Oct 2026
- Encounter End
- 17 Oct 2026
Care team
- Care Team
- 3 member(s)
Diagnoses
- Diagnoses
- M17.11 (Principal), E11.9, I10
Services
- Services
- 3 service(s)
- Grand total
- SAR 27,600.00
Supporting info and links
- Supporting Info
- 2 item(s)
- Related Claims
- 2 claim(s)
BackDraft saved 2 minutes agoSaved in RaneemHCP only. Nothing is sent to NPHIES until you submit the request.Clear formSave draftSubmit prior authorization
1 section needs attention. Care team: add at least one care team member. Professional requests cannot be sent without one. Go to Care team
Grand total
SAR 27,600.00
Quantity times unit price
Payer Share (SAR)
22,080.00
80%
Patient Share (SAR)
5,520.00
20%
Care team
0
Add a care team member
Prior authorization setup
- Claim Type
- Professional
- Sub-Type
- Inpatient
- Priority
- Normal
- Service Date
- 14 Oct 2026
- Authorization type
- Prior authorization
Patient identity
- Patient Name
- Noura Al Harbi
- ID Number
- 1087654321
- Date of Birth
- 17 Apr 1991
- Gender
- Female
Insurance and coverage
- Payer ID
- 7000911508
- Insurance Company
- Bupa Arabia
- Member Card No.
- 4410 2287 6035
- Policy Number
- BP-77120934
- Coverage Type
- EHCPOL
- Facility Name
- Al Raneem Hospital
- Facility Type
- HOSP
Clinical context
- Encounter Start
- 14 Oct 2026
- Encounter End
- 17 Oct 2026
Care team
- Care Team
- Required, no data entered
Diagnoses
- Diagnoses
- M17.11 (Principal), E11.9, I10
Services
- Services
- 3 service(s)
- Grand total
- SAR 27,600.00
Supporting info and links
- Supporting Info
- 2 item(s)
- Related Claims
- 2 claim(s)
BackDraft saved 2 minutes agoSaved in RaneemHCP only. Nothing is sent to NPHIES until you submit the request.Clear formSave draftSubmit prior authorization
NPHIES is not answering. Your request is saved and will be sent when it is back. Save it now. RaneemHCP sends it when NPHIES is back.
Grand total
SAR 27,600.00
Quantity times unit price
Payer Share (SAR)
22,080.00
80%
Patient Share (SAR)
5,520.00
20%
Care team
3
Primary: Dr. Faisal Al Otaibi
Prior authorization setup
- Claim Type
- Professional
- Sub-Type
- Inpatient
- Priority
- Normal
- Service Date
- 14 Oct 2026
- Authorization type
- Prior authorization
Patient identity
- Patient Name
- Noura Al Harbi
- ID Number
- 1087654321
- Date of Birth
- 17 Apr 1991
- Gender
- Female
Insurance and coverage
- Payer ID
- 7000911508
- Insurance Company
- Bupa Arabia
- Member Card No.
- 4410 2287 6035
- Policy Number
- BP-77120934
- Coverage Type
- EHCPOL
- Facility Name
- Al Raneem Hospital
- Facility Type
- HOSP
Clinical context
- Encounter Start
- 14 Oct 2026
- Encounter End
- 17 Oct 2026
Care team
- Care Team
- 3 member(s)
Diagnoses
- Diagnoses
- M17.11 (Principal), E11.9, I10
Services
- Services
- 3 service(s)
- Grand total
- SAR 27,600.00
Supporting info and links
- Supporting Info
- 2 item(s)
- Related Claims
- 2 claim(s)
BackDraft saved 2 minutes agoSaved in RaneemHCP only. Nothing is sent to NPHIES until you submit the request.Clear formSave draftSave and send later