27 February 2026
As part of its ongoing efforts to protect the interests of the health insurance stakeholders and insureds by accelerating medical insurance transaction procedures for health insurance policyholders and beneficiaries, while ensuring greater accuracy and reliability, the Insurance Authority has announced the implementation of five significant clinical edits to the medical coding system used through the NPHIES (SHIB) Platform, which is responsible for the digital linking between insurance companies and healthcare providers, including hospitals, medical centers, and other entities.
These 5 edits aim to enhance the use of highly accurate and reliable diagnostic codes by insurance companies and medical service providers, in accordance with the Australian Coding Standard, thereby contributing to faster medical approval procedures.
The new Edits introduce a precise mechanism for the instant verification of diagnostic data between medical service providers and insurance companies. The system will block inaccurate transmissions and ensure the provider selects a diagnosis from the list of ICDs allowed for billing. The edits verify that the service date/period of the item linked to the principal or secondary diagnosis falls completely within all active periods of the linked International Classification of Diseases (ICD). The edits also ensure that the patient's gender matches the selected diagnosis code within the ICD list, confirm that the chosen diagnosis code is permitted for principal diagnosis per the ICD, and verify that the diagnosis code is age-appropriate for the patient, along with a range of additional enhanced features.
The Authority has also assessed the readiness of NPHIES (SHIB) platform users to implement these edits and develop the health insurance-related transactions in line with the highest international standards. This includes leveraging modern technologies to enhance transparency, improve beneficiary experience, promote public health outcomes, and increase the efficiency of the health insurance sector.
As per Council of Ministers Resolution No. (85) dated 15/8/2023, all supervisory and regulatory responsibilities over the insurance sector, as stipulated in the Cooperative Insurance Companies Control Law and the Cooperative Health Insurance Law, have been transferred to the Insurance Authority.