In Saudi Arabia, the average healthcare claims rejection rate is around 20% - 25% for small and medium-sized hospitals. This translates to delays and loss of revenue amounting to 3.5 – 4.5 billion SAR every year. This figure is poised to increase further as the healthcare market gears up to increase its market size to 141 billion SAR by 2030.

Getting around the issue of claims rejections requires specialized knowledge of what causes these rejections in the first place. Here are 9 reasons that contribute to the rejection rate for healthcare claims in Saudi Arabia.

Factors Affecting Rejection of Provider Healthcare Claims

Lack of Medical Necessity or Appropriateness of Care

Medical necessity adjudication is a complex process, especially in the local market. It is primarily due to the lack of standardized medical documentation and clinical practice guidelines. Ideally, medical claims should serve a well-defined diagnosis/problem as a clear justification. However, most of the local medical practitioners have been trained to rely on exploratory testing to formulate an understanding that has shown to be cost-ineffective—as a result, submitting a claim with an inaccurate or inappropriate diagnosis mostly leads to a denial for excessive or unnecessary service. Using GlanceClaim™ Checker, 40.5% of the analyzed claims lack appropriate justification.


Policyholder Influence

One of the uniquely disruptive factors that affect the medical claim quality is the patient (policyholder) influence on the decision-making. For instance, patients may influence the medical practitioner to gain certain services without a justified medical reason. 


Low-quality Medical Documentation

In January 2020, the Saudi health council mandated the Australian coding standard for inpatient encounters. However, it has been challenging to implement this change due to insufficient medical coding personnel. We found that 27.8% of the analyzed claims suffered from coding errors.


Non-compliance with Regulations

Medical claim filing in Saudi Arabia follows specific standards and requirements appointed by the local regulator, i.e., the Saudi Council of Health Insurance (CHI), to ensure adequate and fair claims processing/reimbursement. Standards include utilizing the unified claim and approval form (UCAF / DCAF 2.0) and the claim’s minimum data set (MDS v3.1). Failure to comply with these requirements jeopardizes the claim’s integrity and fair reimbursement. We found that most of the healthcare providers are not fully compliant. Financial limitations, operational restrictions, and technical immaturity played a major role. 


Technical Limitations

Accurate transmission of data between stakeholders is one of the most significant challenges in the Saudi market. The reason for this appears to be a lack of standardized data transmission protocols. However, the new regulatory changes adopting the National Platform for Health and Insurance Exchange Services (NPHIES) standards, which are a local modification of HL7-FHIR standards, will significantly improve the market's technical infrastructure, allowing for greater interoperability and better data exchange. Reflecting on the sampled EHR systems, 2 out of 3 are non-compliant with the minimum data set (MDS v3.1) requirements due to limitations in the system’s data architectural design.


Non-adherence to the Payer or National Unified Medical Policies

Contractual terms and policies govern the reimbursement process, which includes pricing, communication standards, pre-approval policies, financial considerations, etc. However, translating these terms into effective processes is operationally challenging, expensive, and potentially restrictive to the workflow. We found that 2.9% of the studied claims lacked adherence to medical policies.


Invalid Membership

Payers consider expired subscriptions, invalid relationships, or inaccurate plan details invalid membership. This issue was more prevalent among busy HCPs with poor internal processes. However, NPHIES ensure current and accurate data transmission for instant validation.


Consumed and Exhausted Benefits

The policyholder may consume more benefits than the policy allows, which creates a reason for denial. Due to the lack of transparency in information exchange between stakeholders, policyholders may abuse loopholes. Consequently, we found that HCPs rely heavily on requesting pre-authorization to mitigate the risk of claims rejection.


Medically Harmful Services

When adjudicating claims, some of the major insurance companies in the Saudi market consider patient safety as a denial measure. For example, prescribing an intravenous antibiotic without proper indicative documentation or co-administering multiple drugs without checking for interaction are the bases for many reimbursement denials. Without appropriate clinical decision support systems, patient safety should remain a valid reason for claims denials in the market.


Late Filing

With the overwhelming daily operations, submitting claims on time is one of the HCP’s most stressful tasks. Without supportive workflow, infrastructure, and policies, HCPs continue to trade between claim quality versus timely monthly filing.


How Can Healthcare Providers Increase Claim Approval Rates?

GlanceClaim™ is designed to improve the quality of medical claims by detecting and resolving medical and technical vulnerabilities. This solution has been developed keeping the Saudi healthcare sector in mind and helps 3 key stakeholders of the healthcare-insurance claim cycle – the medical team, the RCM team, and executive management. GlanceClaim™ also reduces coding discrepancies by up to 87%. Read the whitepaper or learn more about GlanceClaim™ here.


Epistaxis (nosebleed) is a common ear, throat and nose medical emergency. It occurs due to a rupture in a nasal blood vessel or a group of vessels. It can be classified as anterior or posterior nosebleed. Anterior nosebleed is more common but less significant, however posterior nosebleed is less common but more significant. Majority of anterior nosebleeds are identified within Kiesselbach's plexus (Little’s area) located on the anterior nasal septum.[1]

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

Introduction to Epistaxis

The arterial vasculature of the nasal cavity arises from the terminal branches of five arteries [1].

The watershed of the five main arteries is located at the anterior nasal septum, including Kiesselbach's plexus (Figure 1.0). The Anterior nasal septum is located at the entrance of the nasal cavity, therefore is subject to environmental triggers such as heat, cold and moisture. This makes it more susceptible to trauma. In addition, the majority of nosebleed takes place at this site, due to the very thin mucosa that lines the septum. Anterior Epistaxis is more commonly reported compared to posterior epistaxis. In addition, anterior nosebleeds are usually caused by local trauma such as rupturing the nasal septum blood vessels by finger scratching or inserting a foreign object in the nostrils. However, if vessels in the posterior or superior nasal cavity bled, posterior epistaxis then occurs. Posterior epistaxis is usually due to systemic causes, such as hypertension or coagulopathies and is more reported by adults.[1][2][3]

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)



Epistaxis results from a rupture in a blood vessel in the nasal mucosa. This usually happens due to trauma. Since thin mucosa lines up the Anterior nasal septum, the blood vessel becomes highly susceptible to injury. The bleeding can be spontaneous, medication induced or secondary to a comorbidity such as hypertension or melanoma. Bleeding due to trauma is usually acute and resolves on its own. However, when a comorbidity is involved, the bleeding can be more serious. Specific medications can increase the chance of nosebleed. It is usually assumed that posterior nosebleeds take place at terminal branches of the sphenopalatine and posterior ethmoidal arteries named Woodruff's plexus. Blood can enter the nasopharynx, which is then swallowed and can be coughed. Posterior epistaxis is usually harder to control due to the high blood flow compared to anterior epistaxis. [1]

(Cho and Tabassom. StatPearls Publishing.2021)



There are a plethora of causes to nosebleed. The causes include, but are not limited to systemic, local, medication-induced and environmental [1]. While the ones mentioned below are the most common causes of epistaxis, rarer etiologies such as neoplasms and malformations should be considered in the diagnosis. [4][5][6]

Local Causes


Systemic Causes

Environmental Factors

Medication Induced

Tumors and Aneurysms

 Juvenile angiofibromas

(Cho and Tabassom. StatPearls Publishing.2021)

 Visual Representations

EPISTAXIS - Figure 1.0

Figure 1.0: The five arteries that supply the anterior nasal septum. Kiesselbach plexus is a common site of anterior epistaxis. (S Bhimji MD, StatPearls Publishing LLC.) [1]

(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

EPISTAXIS - Figure 2.0

Figure 2.0: The main symptom of epistaxis is bleeding from the nostrils. The blood flow can range from drops to a stream of blood based on the severity and the location of the ruptured blood vessel. 90% of anterior epistaxis is due to trauma within Kiesselbach's plexus [1]. ( ) (License: )

Differential Diagnosis

In the presence of nosebleed, it is necessary to perform a differential diagnosis by an accurate history, physical examination and diagnostic tests. If the bleeding is very significant, it is necessary to first stop the bleeding and stabilize the patient.

Key Differences between Anterior and Posterior Nosebleed

Anterior Epistaxis

Posterior Epistaxis

(Cho and Tabassom. StatPearls Publishing.2021)


(Ayesha Tabassom & Julia J. Cho. StatPearls Publishing.2021)

Physical Examination

(Cho and Tabassom. StatPearls Publishing.2021)

Management and Treatment

Anterior Epistaxis

Posterior Epistaxis

(Cho and Tabassom. StatPearls Publishing.2021)



1)Tabassom A, Cho JJ. Epistaxis. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:

The article is mainly adapted from the source above - by : Ayesha Tabassom; Julia J. Cho.

Including figure 1.



Additional Resources and Clinical Studies


The COVID-19 Pandemic has not only wrecked havoc upon the healthcare sector and has endangered the lives of millions, but has also almost equally affected businesses and economies. It has also affected each individual person differently. Everyone seems to be affected and stuck under the additional burdens and loads posed by the COVID-19 crisis, and it is almost evident that coming out of this crisis and burden would no doubt be a hard and time-consuming task. 


If we talk in particular about the people who are directly affected by it - that is, the healthcare personnel and the junior doctors and students, then they have undoubtedly had their fair share of loss and have faced a lot of troubles with regards to their studies and practice and clinical rotations. 

How Has COVID-19 Affected Medical Students and Junior Doctors?

As this is a well-established fact that a doctor is useless without any practical implementation of his skills, then this very fact could prove to be very disappointing and discouraging for all the aspiring medical students and junior doctors because they can no longer be exposed like before to the patients and try out their skills. 

With the advent of COVID-19, the entire educational sector was forced to move to virtual platforms. This seemed favorable at that time as keeping the health of both the tutor/facilitator and the student was the main priority.
For medical students, this was not that favorable. More than half of their studies is based on real-life patients and real-time clinical scenarios.
This sudden shift from live, hospital exposure to a screen-bound platform was not only limiting, but also caused an immediate rift to be created in their studies and clinical exposure.

When a group of Final Year Medical students from the UK was asked to give their opinions on how COVID-19 affected their studies and most importantly their clinical observerships, the majority of the students expressed their disappointment and reacted that they were reluctant to continue the upcoming academic year as they had to safeguard both - their lives as well as their future careers at a time as crucial as this.

The Bottom Line:

Medical students and junior doctors who are yet to start their training years feel confused about their next step - there has been a definite and visible education gap which has done no good but only created problems for everyone out there. There still exists an uncertainty about how long this pandemic will last and for how long it will continue to keep us restricted within our homes.
But one thing is evident - the students of today and the doctors of tomorrow would be more well-versed than us on how to deal with large-scale problems and disease outbreaks like the one that they are experiencing at a time like this. 



  1. Hilburg R, Patel N, Ambruso S, Biewald MA, Farouk SS. Medical Education During the Coronavirus Disease-2019 Pandemic: Learning From a Distance [published online ahead of print, 2020 Jun 23]. Adv Chronic Kidney Dis. 2020;doi:10.1053/j.ackd.2020.05.017
  2. Choi, B., Jegatheeswaran, L., Minocha, A. et al. The impact of the COVID-19 pandemic on final year medical students in the United Kingdom: a national survey. BMC Med Educ 20, 206 (2020).
  3. Yasmeen M. Byrnes, Alyssa M. Civantos, Beatrice C. Go, Tara L. McWilliams & Karthik Rajasekaran (2020) Effect of the COVID-19 pandemic on medical student career perceptions: a national survey study, Medical Education Online, 25:1, DOI: 10.1080/10872981.2020.1798088