Approval Officer

1 week ago


Dubai, Dubai, United Arab Emirates NMC Healthcare Full time

The main responsibility of the insurance department is to process pre-approvals from the In-network insurance companies, so that the patient's can avail cashless treatment for the approved services.


Direct Billing:
Cashless treatment given to patient with or without taking the approval form the In-network insurance companies. The charges will be later claimed from the insurance by the claims department.

Cash & Reimbursement:

Patient's belonging to out of network insurance companies need to pay the cash and later get it reimbursed from the insurance companies with a claim form filled by the doctor.


Pre-Approval:

It is a guarantee of payment or a "go ahead" given by the In-network insurance companies to the hospitals for rendering the direct billing (cashless) facility to the patient's for the approved services.

Pre-approval is requested from the insurance in the following scenarios:

  • If the cash limit (given by the insurance) is exceeded
  • _Refer handbook, _
  • If the service falls under the list of services which requires preapproval
- _Refer handbook _,

  • All IP and daycare cases.

Query:

When the data provided to the insurance is insufficient, they send us in a form of query which needs to be replied by the treating doctor with his/her sign and seal.


Rejections:

The insurance will reject services which falls under general exclusions, If the benefits are exhausted and if the services are not medically justified.


Reconsideration:

Once the service is rejected by the insurance company, the treating doctor can appeal the decision by writing a justification/reconsideration request.


General Exclusions:

Certain services under each insurance company are excluded and the payment related to these services are to be borne by the patient.


Ex:
Infertility, Chronic conditions etc.

O need to check the below check list and if anything is incorrect or missing, need to send the approval for revision

  • Verifies customers' insurance eligibility and authorization in a timely and accurate manner
  • Communicates payer authorization and eligibility information.
  • Sends payer informational correspondence.
  • Complete service and procedure authorizations and referrals
  • Review the patient's medical history and insurance coverage for approval.
  • If necessary, contact referral physicians for more information.
  • Once approval is obtained, the concerned staff and treating physicians should be notified.
  • Enter new patient information and update data in our system.
  • As needed, assist with other doctors indications responsibilities.
  • Notifies branch management of concerns with payer coverage or other service noncoverage.
  • Keep track of the daily production report.
  • Keep the pending approval monitoring system updated for the next day's followup.
  • The supervisor and team leader will monitor the schedules and emergency requirements and all the quires from the facility.
  • Guide the doctors and concerned doctors, nursing staff and other staff to follow the correct ICD, CDT and CPT codes to avoid the rejection.
  • Equivalent to the position


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