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Almadallah Providers Manual – Version06 – May, 2018
P
Almadallah Healthcare Management FZ LLC P.O. Box
478803 Dubai International Academic City Building No. 3,
Office No. 8 Dubai, United Arab Emirates
P
Almadallah HealthCare Management
PHARMACY MANUAL
Version 6 – May 2018 i
The revised edition of Almadallah Healthcare Management Pharmacy Manual is
intended to provide necessary assistance to our healthcare providers with
valuable information. The goal of this document is to give a broad overview of
the main function of pharmacy network providers conferring to terms and
polices of the contractual agreement set forth and in accordance to DHA/HAAD
guidelines.
Every effort has been made to ensure that this manuscript is an accurate
representation of the functionality of Almadallah Healthcare Management as
Third Party Administrator (TPA).
We make every effort to ensure the delivery of quality healthcare services to our
members through circumspect selection of Almadallah’s network healthcare
providers.
The general objective of these pharmacy manual is to standardize the provision
of clinical pharmacy services, thereby optimizing patient outcomes by ensuring
the rational use of medicines.
Preface
Version 6 – May 2018 ii
ALMADALLAH CARD ........................................................................................................................ 1
PHARMACIES .................................................................................................................................... 2
APPLICABLE DENIAL CODES ........................................................................................................ 5
ALMADALLAH EXCLUSION LIST ................................................................................................... 6
Treatment ........................................................................................................................................... 6
Pharmacy Exclusions ......................................................................................................................... 7
Pharmacy items/medicines related to Diagnostic Procedure ............................................................. 8
ALMADALLAH PRE-APPROVAL PROCEDURES .......................................................................... 9
Pre-approval Procedure ..................................................................................................................... 9
CLAIMS SUBMISSION AND RECONCILIATION ........................................................................... 10
Claims Submission/Resubmission .................................................................................................... 10
Reconciliation .................................................................................................................................... 10
Claim Status ...................................................................................................................................... 11
CONTACT DETAILS ........................................................................................................................ 12
APPENDICES:
Appendix A – Almadallah Claim Form ............................................................................................ 13
Appendix B – Almadallah Pre-Authorization Form .......................................................................... 14
Appendix C – Online Directory ......................................................................................................... 15
Member Login .................................................................................................................................. 15
Member Utilization ......................................................................................................................... 15
Claims Report ............................................................................................................................... 15
Payment Details-Reimbursement .................................................................................................. 16
Reconciliation Report ..................................................................................................................... 16
Provider Login ................................................................................................................................ 17
Claims Report ............................................................................................................................... 17
Batches Received-Direct ............................................................................................................... 17
Appendix D – Almadallah Invoice Form .......................................................................................... 18
Appendix E – Almadallah Detailed Statement of Accounts Form ................................................... 19
Appendix F – Almadallah Reconciliation Report Form ................................................................... 20
Appendix G – Almadallah E-Statement .......................................................................................... 21
Appendix H – Almadallah Resubmission Report Form ................................................................... 22
Appendix I – Almadallah E-Claim Submission Guide ..................................................................... 23
FREQUENTLY RAISED MEMBER CONCERN .......................................................... ……….24
Table Of Contents
Version 6 – May, 2018
1
LOGO
ALMADALLAH CARD
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2
1. Pharmacist should check the Almadallah card with drearily packed stamped
copy of the claim form and original prescription.
2. Pharmacist should verify the card for its validity, member category and for any
specific Indications/conditions. Please verify the member’s Almadallah card with other valid personal ID for Almadallah
members visiting your facility. For parents/guardian of minors/children members, please verify with their personal ID with the members’ ID
3. Confirm eligibility (e.g. network, validity) - Check eligibility through our
online portal by logging in www.almadallah.ae with provided login credentials
4. The Expiry Date is the date that the insured member’s policy benefits and
ability to receive direct billing services at your facility expires.
Cards for some self-funded schemes do not have an expiry date - Those
cards are valid for unlimited period unless advised otherwise
Cards with expiration dates
The expiry date is inclusive of the end date
For example: Expiry Date = 31-Dec- 2010
A consultation occurring on December 31, 2010 is inclusive up to 12 midnight
For chronic medications: when the prescribed period is beyond the expiration
date, Almadallah must be billed until the expiry date only. The rest of the
medicines have to be billed to the member directly.
Claims received by Almadallah relating to expired cards will not be paid and will
be the provider’s responsibility.
5. Coverage: Our members will have different coverage guidelines according to
the current group and categories:
Pre-approval is NOT required to VIP members, either for In-patient or
Outpatient Services. However, standard exclusions apply for all categories.
DUBAI GOVERNMENT MEMBERS:
Category VIP: General Network + (GN+) & DHA facilities
Category A: General Network + (GN +) & DHA facilities
Category B: General Network (GN) & DHA facilities
Category C: General Network (GN) & DHA facilities
Category D: Restricted Network (RN) & DHA facilities
PHARMACIES
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3
Pre-approval indication applies to all member for applicable medical
services. Standard exclusions apply for all categories.
DUBAI HOLDING MEMBERS:
Category A: General Network + (GN+) & DHA facilities
Category 1: General Network (GN) & DHA facilities
Category 2: General Network (GN) & DHA facilities
Category 3: Restricted Network (RN)
*Category 4: Restricted Network 2 (RN2) / Health Maintenance
Organization (HMO)
*Medical services (including medications) more than AED 150.00 requires
pre-approval (except GP consultation) and referral letter from GP for
Specialist consultations
Insurance based policies as per Table Of Benefits/Almadallah Card
6. Verify that all fields in the Claim Form are properly accomplished:
ACCURATELY AND CLEARLY by healthcare providers.
7. It is the pharmacy personnel’s responsibility to check the member’s
card and complete any missing information in the Administrative part of the
Claim Form.
8. VIP cards: A card with category VIP printed on it means that the card holder
is a very important person and should be attended to immediately and with
special assistance. Pre-approval is NOT required for members with
Category A VIP or A V for neither In-patient nor Outpatient Services.
However, standard exclusions apply for all categories unless otherwise
specified.
9. Pre-approvals are valid for a maximum of 10 calendar days during which the
pre-authorized services should be rendered. If the service was not rendered
or if it was rescheduled for another day, then the same request has to be re-
approved unless otherwise specified for Insurance related claims
10. See Exclusions List & Pre-approval Indications per the Almadallah
Pharmacy Guide
Check if the prescribed medicines are excluded or require pre-approval
Pre-approval required for all Maternity prescriptions
Pre-approval required for all Dental prescriptions
Pre-approval required for all Optical Eye-ware
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4
Any medication related to:
All In-patient admissions
All Daycare/short stay admission
Major and minor surgeries
All work-related injuries
Trauma cases (mentioning the history of the trauma is mandatory)
11. Please note that Pre-approval is required only in cases where chronic
medication is prescribed for more than 3 months’ supply or medications with
cost more than AED 2000, unless otherwise specified for Insurance related
protocols.
12. Dispense the prescription strictly according to the directions of the
physician and according to the Almadallah Healthcare Policy coverage.
Please refer to the Almadallah Pharmacy Guide.
13. For medications that are not authorized or excluded, 100% of all related
charges should be collected from the patient after applying the agreed upon
Network Discount.
14. For eligible/authorized cases, any applicable co-participation amount, after
applying the discount, must be collected from the patient and the eligible
remainder should be billed to Almadallah.
15. A copy of the prescription can be provided to the patient upon request.
16. Medications that are not medically necessary, not medically appropriate,
not related to diagnosis and medications not prescribed by the treating
physician are not coverable.
17. Almadallah Healthcare Policy covers 2 weeks Home Nursing as per the
treating physician’s medical report. Pre-approvals are required for all
Homecare Nursing Pharmacy related services.
18. Drugs not available in DDC list can be approved and added to list by
sending to pharmacist in-charge
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5
APPLICABLE DENIAL CODES ON PBM/PRIOR REQUEST CLAIMS:
1. Drug Duplicate Therapy – As per DHA guidelines whenever medication falls
under duplication - Service is not clinically indicated based on good
clinical practice (MNEC-003)
2. Drug to Disease Contraindication - As per DHA guidelines contraindication
between drug to drug and drug to disease - Service is not clinically
indicated based on good clinical practice (MNEC-003)
3. Difference in claimed amount and approved amount - less than AED 1.00 -
Calculation discrepancy (PRCE-001)
4. Difference in claimed amount and approved amount - more than AED 1.00 -
Submission not compliant with contractual agreement between provider
& payer (CLAI-012)
5. Service not indicated - Service is not clinically indicated based on good
clinical practice (MNEC-003)
6. Service requires Medical report attachment - Service is not clinically
indicated based on good clinical practice, without additional supporting
diagnoses/activities (MNEC-004)
7. Duplicate Service - Claim is a duplicate based on service codes and
dates (DUPL-001)
8. Quantity claimed by provider is more than to be - Service/supply may be
appropriate, but too frequent (MNEC-005)
9. Service Exclusion - Service(s) is (are) not covered (NCOV-003)
Denial Codes applicable if necessary:
Co-participation not collected from patient/member (COPY-001)
Discount discrepancy (PRCE-011)
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A. Treatment Exclusions
1. Developmental delays
2. Learning disorders
3. Attention deficit disorders
4. Eating disorders
5. Anorexia
6. Obesity (unless mentioned otherwise)
7. Vaccinations except for newborns in the 1st 3 days of life + Tetanus & Anti-
Rabies in case of infection (only under DHA)
8. Infertility
9. Fertility
10. Sexual dysfunction
11. Sterility
12. All Preventive care
13. Check-ups including well baby check-up
14. Work permit related health screening except for the Antenatal screening
tests
15. All LASIK services & procedure
16. Plastic, Cosmetic surgery & treatment including any non-medically
necessary nasal surgery, unless relating from an accident which occurs after
the first enrollment date under the policy
17. Substance abuse
18. Addiction or Alcoholism
19. Radiation contamination
20. Professional sports injuries & not job-related sports
21. Hair loss, Dandruff, hair transplant , hair disorder
22. Home visit except in the case of emergency i.e. life threatening condition
and /or requiring inpatient admission
23. Genetic engineering and cloning
24. Diseases designated by the WHO as epidemic
25. Organ donation
26. Orthodontist services
27. Services or treatment in a long term care facility rehabilitation center, spa,
hydro, rest care, sanatorium, home care, nursing home for the aged, periods
of quarantine and or isolation.
28. Ambulance services Except transfer patient from home to hospital in
emergency case only & body of the patient who has expired from hospital to
home
ALMADALLAH EXCLUSION LIST
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29. All Alternative Medicine such as but not restricted to : Acupuncture,
Acupressure , Osteopathy ,Chinese Medicine, Chiropractic, Cupping Therapy,
Homeopathy, Naturopathy , Ozone Therapy, Ayrovudics, Chiropody, Herbal
Therapy ,Reflexology, Aromatherapy, Hypnotherapy, Apitherapy,Colonic
Cleansing, Color therapy, Gemstone Therapy, Holistic Health, Iridology, Breath
Work, Kinesiology, Body Work, Buteyko, Flower Essences, Polarity Therapy,
Therapeutic Touch, Yoga, Crystal Therapy, Orthomolecular Medicine, pranic
Healing, Radionics, Therapeutic Humor, Traditional medicine, Herbal medicine,
Nutrition medicine, Anthroposophical Medicine, Music Therapy, Ear Candles,
Light Therapy, Magnetic Therapy, Massage Therapy, Qigong, Reiki,
Counseling Therapy
B. Pharmacy Exclusions
1. Fertility, Infertility related medicines/agents
2. Sexual dysfunction medication
3. Sunglasses, contact lenses solutions and accessories (unless otherwise
specified)
4. Appetite stimulants, appetite suppressants, dietary preparations
5. Oral hygiene, non-medicated lozenges, oral sprays dental and gum related
medicines and products, etc.
6. Contraceptive medicines and products
7. Cosmetic products, lotions, moisturizers, sunscreens, skin-lightening
agents, masks, face , cleansers, antiseptics, alcohol, etc.
8. Anti-oxidants, liver tonics
9. Oral rehydrating solutions between the ages of 10 – 65 years old
10. Soaps, shampoos, cleansers
11. Hair and scalps preparations
12. Routine vaccinations /Immunizations. Except for neonatal in the 1st 3 days
of life or until discharge
13. Vitamins, minerals and supplements, except those prescribed in adjunction
with anti-biotic, prescriptions to treat vitamin deficiencies (e.g. Resulting
from Anemia, diabetes)
14. Smoking cessation, substances abuse medication
15. Pain balms, rubefacient joint maintenance products and non-medicated
preparations
16. Crepe bandages, disposables, glucose strips, lancets
17. Castor oil, cod liver oil, clove oil, Eucalyptus oil, karvol ,etc.
18. Diaper/Nappy rash cream, formula, baby supplies
19. Artificial tears, liquifilm, dura tears, normal saline for patients over the age
of 10 years
20. Homeopathic preparations, preventive medicines, except those in the MOH
list as listed in the Al Madallah pharmacy Guide
21. Medications that are not medically necessary, not medically appropriate,
not related to diagnosis and medications not prescribed by the treating
physician
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8
22. Immunomodulator drugs and/ or immunotherapy treatment unless
medically necessary
Basiliximab
Daclizumab
Rho (D) immune globulin
Methyl Prednisone
Mycophenolate mofetil
Sirolimus
Cyclosporine
Tacrolimus
Azathioprine
Etanercept
Infliximab
• Biological response modifier
• Biological response modifier
• Biological response modifier
• Glucocorticoid
• Immunomodulator
• Immunomodulator
• Immunomodulator
• Immunomodulator
• Immunomodulator
• Rheumatoid arthritis drug
• Rheumatoid arthritis drug
C. Pharmacy Items/Medicines Related to Diagnostic Procedures
1. Fertility, Infertility related tests and procedures
2. AIDS/HIV Related tests and procedures (including pre-operative) except
in antenatal maternity checkup)
3. Preventive tests and checkups
4. Screening tests and procedures (except for Maternity, please refer to
Maternity Protocols at the end of the Manual)
5. Employment related check-ups
6. Any tests not prescribed by a medical doctor licensed by MOH/DHA and
not under the Almadallah Network
7. Any tests related to excluded consultation
NOTE: Other Treatment/Medication can be covered in some cases for
certain group or members unless otherwise specified for Insurance
related protocols.
Please inquire to Call Center for more information (and request
for pre-approval if necessary)
Version 6 – May, 2018
9
PRE-APPROVAL PROCEDURE
APPLICABLE TO ALL CATEGORIES EXCEPT CATEGORY VIP
Pharmacy items/medicines under pre-approval list:
a. Pharmacy items/medicines listed under pre-approval indications require
Verbal Pre-Authorization to be obtained by calling Almadallah at 04-
5591322 or submitting request for approval through DHPO for
DHA/MOH Hospital and Al Shafafiya Portal for HAAD providers.
b. Register the name of the person granting the approval and proceed with
dispensing the item/medication. The Verbal Pre-authorization form will be
e-mailed or faxed within 2 hours. Kindly provide correct fax numbers
to prevent discrepancies.
c. The Claim Form, Verbal Pre-authorization Form and Invoice/s SHOULD
be attached when submitting Claims for payment.
d. To avoid duplication, kindly refer to eRx Claims Submission Guide (See
Appendix I, page 23)
PRE-APPROVAL PROCEDURES
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10
A. CLAIMS SUBMISSION
1. Claims must reach Almadallah no later than 30 days (or as per contractual
agreement) from end of the month from date of service or patient discharge or
as indicated in the contract for eligibility of payment.
2. Submitted Claims should be clearly and completely filled and all relevant
supporting documents as medical report, results of all investigations done,
original prescriptions, discharge summaries (for In-Patient) must be attached.
3. Please submit each Batch of Claim Forms with the following:
a. The Original Itemized Invoice.
Kindly document and apply the % discount as per contract
on each Invoice
b. Detailed Statement Of Account.
4. Individual Claims (and accompanied documents) should be separated and
batched per Payer.
5. Each batch should be accompanied by Detailed Statement of Account Form
for that payer. The Detailed statement of Account should enlist the details of all
physical claims submitted for that particular payer within the allocated billing
period. (See Appendix E, page 19)
6. Payments are provided as per the terms of the Contract Agreement. Cheques
along with Payment Orders, Transaction Details and Batch Summary Report will
be provided.
B. PROCEDURE FOR RE-SUBMISSION
a) Re-submission should be made within 30 days (or as per contractual
agreement) of receiving the returned Claims or as per contract. Please
complete with Resubmission Form accordingly (See Appendix H, page 22)
b) Re-submit the missing documents as requested in the Reconciliation Report
and include a photocopy of the returned Claim Forms along with a copy of
the Reconciliation Report sent by Almadallah (See Appendix F, page 20)
CLAIMS SUBMISSION & RECONCILIATION
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11
C. CLAIM STATUS (see Appendix C, page 15)
After evaluation, Almadallah can return/reject the claims due to the
following reasons as will be stated clearly on the Reconciliation Report
Form submitted at the time of payment:
Technical Denial: (Missing Document/s): Claim form along with all documents
will be returned back to the provider. One or more missing document/s are
required (reason for denial will be mentioned in the Reconciliation Report).
Partial Denial: Claim amount is partially denied as per policy terms and
conditions. A copy of Claim and documents will be provided with the Payment
Order. (reason for denial will be mentioned in the Reconciliation Report).
Full Denial: The claim amount is entirely denied as per policy terms and
conditions. A copy of the Claim and documents will be provided along with the
Payment Order. (reason for denial will be mentioned in the Reconciliation
Report).
Final Denial: These are denials after re-evaluation of re-submitted claims. The
decisions are final and re-submissions are no longer considered.
Version 6 – May, 2018
12
FOR PRE-APPROVALS
Call Center: 04-5591322 (24/7)
E-mail: claims@almadallah.ae
FOR ADMINISTRATIVE ISSUES
info@almadallah.ae
FOR MORE INQUIRIES
Claims Submission/Resubmission or order claim form:
reception@almadallah.ae
Clarification of Claims Rejections/Denials:
auditandreconciliation@almadallah.ae
Network Inquiries: network@almadallah.ae
Account Inquiries: accounts@almadallah.ae
Website: www.almadallah.ae
Mailing Address for Claim Submission:
Almadallah Healthcare Management
P.O. Box: 478803.
Dubai International Academic City
Building 3, Office 8
Dubai, United Arab Emirates
CONTACT DETAILS
Version 6 – May, 2018
13
Please Note: White Copy to be used by treating physician. Clearly mention
Providers name and include doctor’s stamp and signature. Yellow or Blue copy
can be used for either Pharmacy or Diagnostic/Laboratory procedures.
Patient’s
Details
Patient’s
Medical
History &
Diagnoses
Physician’s
Treatment Plan
& Prescription
Patient’s/
Guardian's
Signature
Appendix A
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14
Appendix B
Please note: This form will either be emailed to the Provider as per Pre-
approval procedures on page 10
Pre-Authorization
Version 6 – May, 2018
15
Appendix C
Member Login:
Menus
Member Utilization
Claims Report
On-Line Directory
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16
Payment Details - Reimbursement
Reconciliation Report (from above report as link)
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17
Provider Login:
Claims Report
Batches Received – Direct
Version 6 – May, 2018
18
Almadallah Healthcare Management
Invoice Form Provider’s Name: Patient’s Name:
Provider’s Address: Patient’s Card Number:
Provider’s Phone Number: Invoice Date:
Accountant: Invoice Number:
SN
Service
Code
Service
Description
Quantity
Gross
Amount
Discount
%
Discount
Amount
Patient’s Share Net
Amount Deductible Copay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTAL (AED)
NOTES:
Appendix D
Version 6 – May, 2018
19
Almadallah Healthcare Management
Detailed Statement Of Account Batch # (for Almadallah use): Provider’s Name:
Total # of Claims Submitted: Name of Contact Person:
Billing Period: From: E-mail Address:
To: Telephone Number:
Submission Date: Fax Number:
SN
Date of
Service
Invoice
Number
Claim
Form
Number
Patient’s
Name
Gross
Amount
Discount
Amount
Patient’s Share
Net
Amount Deductible Copay
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTAL (AED)
NOTES:
Appendix E
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20
M –
Reconciliation Report
Batch #: Provider: Total Records:
SI Clai
m
No.
Invoic
e
No.
Patien
t/
Memb
er
Claime
d
Cost
Approv
ed
Cost
Denie
d
Amou
nt
Status Clai
m
Actio
n
Reque
st Form
No.
Remarks
( Report by : CLAIM)
Reconciliation Report Batch #: Provider: Total Records:
Bill
Ref.
Service
Price
Collected Service
Claimed
Service
Approved
Rejected
Status
Remarks
(Report by : BILL)
Technically Denied Medically Denied R - Rejected
Appendix F
Above reports are applicable for PHYSICAL claims submissions only
Kindly note the following:
A – Approved T –
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21
Appendix G
E-Statement
Pro
vid
er N
am
e
Receiv
ed
Date
Serv
ice D
ate
Batc
h N
o.
Patie
nt
Card
No
.
Po
licy H
old
er
Su
bm
it/Resu
bm
it
Cla
im N
o.
InP
/ Ou
tP
Inv
oic
e N
o.
Bill N
o.
Serv
ice
Serv
ice C
laim
ed
Serv
ice A
pp
rov
ed
A
mo
un
t
Serv
ice R
em
ark
s
Den
ial C
od
e
Cla
imed
Am
ou
nt
Ap
pro
ved
Am
ou
nt
Reje
cte
d A
mo
un
t
ICD
/CP
T C
od
e
Rem
ark
s
Du
e D
ate
Su
rch
arg
e
Paid
Am
ou
nt
Paym
en
t Ty
pe
Paym
en
t Date
Paym
en
t Ref. N
o.
Ben
efic
iary
Paym
en
t Rem
ark
s
NOTE: E-Statement contains the following information:
Member’s/Patient’s Details are provide (i.e. name, card #, policy #)
Submission Type (submission[initial] / resubmission)
Claim Form Number
Batch Number
Visit Type (Out-Patient / In-Patient / Day case)
Service Rendered
Codes (ICD/CPT/ Denial codes)
Amount (claimed amount / approved amount / rejected amount / paid amount)
Surcharge applied (if requisite)
Payment Reference Number
Dates (received date / service date / due date / payment date)
General Remarks (for whole claim)
Service Remarks (reason of partial payment/rejection) – for easy compliance if eligible resubmission
is necessary) – KINDLY DO NOT RESUBMIT CLAIMS WITHOUT RECTIFICATION AND/OR
JUSTIFICATION
Kindly note that this information is being released to provider per each payment / batch /
cheque
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22
Appendix H
PHYSICAL CLAIMS RESUBMISSION
E - CLAIMS RESUBMISSION
Resubmission Report In Reference To
Batch Number:
Provider’s Name:
SN Patient’s
Name
Card # Claim
#
Invoice
#
Claimed
Amount
Approved
Amount
Denied
Amount
Clarification for
Resubmission
1 ABC 1234 xxx 5678 160.90 100.00 60.90 Justification
2
3
4
5
TOTAL (AED)
NOTE: During claims resubmission, kindly attach the supporting documents (with the photocopy of claim form if required)
& copy of Reconciliation report sent by Almadallah
Claim
Ref
Card No.
Member
Service
Date
Claimed
Cost
Approved
Cost
Action
Resubmission
Type
Resubmission
Comments
xxx
1234
ABC
20 Jan
2016
160.90
-
Pending
Correction
Justification
Version 6 – May, 2018
23
Below are the details from the eclaimLink for eRx claim submission. As per DHA,
after getting the approval for the prior request, provider has to send eclaim for the
same for payment:
No. Transaction From To
Transaction submitted by the Provider/Clinician with the patient information and the
prescription details. Transaction validity is defined by the business rules.
1 eRx Request Provider/Clinician DHPO/eRx Hub
1.1 eRx Request DHPO/eRx Hub Payer/TPA
Transaction submitted by the payer in response to the e-Prescription
2 Prior Authorization Payer/TPA DHPO/eRx Hub
2.1 Prior Authorization DHPO/eRx Hub Provider/Clinician
Transaction to pull the e-Prescription details by the Provider/Pharmacy from the
DHPO/eRx Hub
3 eRx Request DHPO/eRx Hub Provider/Pharmacy
Transaction submitted by the Provider/Pharmacy requesting authorization for the e-
Prescription
4 Prior Request Provider/Pharmacy DHPO
4.1 Prior Request DHPO Payer/TPA
Transaction submitted by the Payer in response to the Provider/Pharmacy request
5 Prior Authorization Payer/TPA DHPO
5.1 Prior Authorization DHPO Provider/Pharmacy
Transaction submitted by the Provider/Pharmacy after dispensing the prescription
6 Claim Submission Provider/Pharmacy DHPO
6.1 Claim Submission DHPO Payer/TPA
Transaction submitted by the Payer in response to the Provider/Pharmacy claim
submission
7 Remittance Advice Payer/TPA DHPO
7.1 Remittance Advice DHPO Provider/Pharmacy
NOTE: Payer should receive the eclaim for the approved prior request for payment. E-claim submission is
related to the system used by the provider. When dispensing the drugs, if the internal system used by the
provider auto send eclaim, then the provider need not submit again as this will be a duplicate claim. If
not only, they should post it in DHPO.
Appendix I
Version 6 – May, 2018
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- Member Eligibility to be checked on Almadallah Portal using the Card
Number or Emirates ID number at all times. If any issue, please contact our 24X7 Call Center 04 5591322.
- Inform the member correctly the reason of rejection (eg. Not covered, pending for more details, etc.).
- Please submit approval request on time in order to avoid delayed approval in order to avoid member waiting for long time for the procedures to be done.
- Kindly do not collect any deposit for any revised approval request from our member and follow contractual agreements as per approval protocols.
- Please submit the correct procedure/CPT request on DHPO in order to avoid any delay.
- Any service paid by member which falls under Exclusion List, kindly do
not advise our member to undergo reimbursement.
FREQUENTLY RAISED MEMBER CONCERNS
top related