Approval Officer

5 months ago

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 pre-approval
- _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.

**Out-Patient services [OP] **:Services without hospitalization

**Day-care/ Day-case**:Ambulatory services or procedures with less than or equal to 12 hours of stay.

**In-Patient**:Services or procedures requiring more than 12 hours of stay.

**Benefits**:Each insurance policy has variable benefits, High-end cards with the maximum benefits and Basic card with less benefits, Benefits are denoted on the cards as OP: Outpatient; IP: In-patient; DN: Dental; MB: Maternity etc.

**Patient responsibility**:A part of the total bill is to be shared by the member Known as patzient responsibilty.

**Example: Copay/Deductible**:An upfront fixed amount applied on consultation & **Coinsurance**: % share on the bill.

**DEPARTMENT WORK FLOW**:_A day in Insurance DepartmentThe below flow chart explains day to day activities performed by the team member:
**IP LIST
It is a report pulled from HIS [Hospital Information System], which gives the list of current admission at that particular time.

Our responsibility is to make sure that the patient's admitted under insurance have approvals for in-patient services until that time, If the approval is not there need to request documents from ward for extension etc.

The IP List is prepared at 3 different times at-least with continuous updates as and when we receive any information from the ward or the doctors.

First at 8 am, as soon as the morning duty staff logs in, then at 1 pm, by the employee on afternoon duty and at 7 pm. A copy needs to be handed over to PRO at 7 PM and if any approval is not there, need to inform PRO, Ward & Billing Team

Following steps shows how to prepare an IP list:

- Login to HIS,
- From the tabs select REPORTS,
- Then click on favorite reports,
- Select IP LIST from the line items and then, Click on CSV, a dialogue box will open, select “open” to view the list in excel format.

Once the sheet is ready format the sheet with the required field, update the list by comparing the approvals received [from the shared folder]

Then call ward to check the status of patient, Example: For discharge, requires extension etc, and update in the sheet using the following abbreviations:
A: Approved

P : Private or Cash patients

*: Needs approval or extension

D: Discharged

4D: For discharge

WA: Waiting for approval

Sometimes if the patient is admitted in the late night, there will only be a verbal approval taken by the ER doctors, we need to Clear the IP's first by requesting claim form and card copy form the ward before moving on the OP requests and follow up's.

**OP REQUESTS
Approval requests for the services intended to be done on OP basis

Once the request is received follow the below steps:
**Documents Required**:Claim Form & card copy
- Check whether the claim form is the right one,
- Check if the services which requires approval are mentioned on a separate post it with CPT codes and their prices.
- Send the claim to coders for code confirmation and take their signature.
- Once the codes are confirmed, verify the price for each CPT code from the CPT PRICELIST - _in Shared Folder. _
- If the request is from Dental department need to write the correct t

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