Approval Officer

1 month 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.

**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 follow-up.
- 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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