INSTITUTIONAL POLICY AND

PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

PURPOSE
To guide the medical team with regards the insurance protocol as to what is covered or not
covered under CCHI, SFDA and Insurance Companies Policy.

DEFINITION
All insurance companies have almost the same way of managing insurance claims according
to certain roles either external from CCHI or internal according to the insurance company
itself.

POLICY
1. It is the policy of the institution to follow the guidelines from the SFDA, CCHI and
insurance companies with regards in insurance approval or insurance protocols.
2. The attending physician is responsible in the overall documentation of patient data and is
liable to any information recorded in the patient’s file.
3. The attending physician is in-charge with all the services to be provided to a patient. In
cases of uncovered services or any clarification, he/she must explain it to the patient
modestly.
4. If patient or significant others are disapproving with regards to their insurance coverage,
refer them to the Insurance Manager.
5. Any personnel in doubt of services to be rendered to insurance card holders as to covered
or not, the Insurance Manager/Insurance Department shall be queried.
6. Compliance to insurance protocol is a must. Failure to comply shall warrant deliberation
with the Insurance Manager and/or CEO if needed.
7. Rejected insurance claims (after appeal, if applicable) of any concerned doctor shall be
dealt as per CEO’s decree.

PROCEDURE

1. Be sure that the patient about to receive a treatment is the cardholder. Gender and age must be
checked initially. It is the responsibility of all staff to ensure no one uses the insurance card
other than the cardholder.

2. Upon examination of the patient, be sure that the disease/condition he complained fall under
the coverage of unified CCHI policy (TOB) which attached with this policy.

3. COVERED MEDICINE

a. Regarding the medication, all insurance companies now are covering some medicines
registered under SFDA protocol, listed below are the format:

i. 00-00-00 – Code format for approved drugs as a chemical medicine

Page 1 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

Example:

CODES MEDICINE
15-7-81 Inderal Tablets 10mg
Please note the 2 last digits (81);

ii. 00-00-0000 – Code format for herbal medicines

Example:

CODES MEDICINE
3-1123-2002 Prospan Cough Syrup
As you notice the last digits combination is 4 (2002) that is for herbal medicine

In general, medicine with two digits in the last combination of the code are covered in
all insurance companies, if medically indicated and the illness is also covered under CCHI
POLICY.

b. For patients with non-chronic illness, the allowed prescription of medicine is only one
box, or depending upon the doctor’s prescription within 10-14 days. Never prescribe
medicines for one-month supply with more than one box as this will be rejected by the
insurance companies. After 14 days, reassessment must be done from the patient. If there
is no good progression of patient condition, a new prescription can be made. Approved
chronic illness can include hypertension, diabetes, thyroid problems, dyslipidemia or any
condition that needs long-term treatment.

c. Some herbal medicines are covered by some insurance companies (only BUPA,
MEDGULF and TAWUNIYA) if there is no other alternative on medication list treating
the same condition as per SFDA list.

d. If medicine/s is prescribed, the full medical indication must be mentioned together with
the signs and symptoms that led to the indication of all given medications. Hence, it is not
logical to give antipyretic with temperature of 37-degree Celsius or give antibiotic with
common colds. It must be specified as to why a medication is given to a certain patient.
Furthermore, all medicines given must coincide with the diagnosis chosen in ICD10-AM
diagnosis codes. In the event of prescription of non-chronic medication of more than one
box (not within 10-14 days), it will be dealt as per CEO’s decree,

Page 2 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

4. For patient’s complaints, treat the main complaint or related complaint. If the patient comes
with acute tonsillitis, acute cystitis, and leg abscess, most insurance companies reject the
treatment of multiple diagnosis at the same time. Kindly treat only the cause that forced the
patient to do consultation in the clinic. For other complaints, refer the patient to other
specialist according to his/her complaint.

5. Patient’s data should have medical information including history, significant clinical finding,
diagnosis, detailed management such as prescribed medicine dosage or wound dressing as
needed by the patient, any treatment was made by the patient with its outcome and duration of
the current patient’s complaint.

6. INVESTIGATIONS/LABORATORIES,X-RAY/ULTRASOUNDS
For any investigation, specify the reason of request, the medical indication, and whether there
is history of same or related investigation done. Previous laboratory results must be indicated
as part of justification to current request. Monitoring guidelines of laboratory requests must
be based on international standards as per the patient’s case. (Refer to S.O.P. of laboratory
test for standard interval of request)
For example:
TLP (Total Lipid Profile) is requested, mention the indication. If there was a previous
laboratory done, mention the result.
(Patient is under -statin treatment, previous result of Triglycerides=190 mg/dL,
Cholesterol=250 mg/dL)

7. Emergency services to be rendered to the patient should have a clear indication. Otherwise the
injection will be rejected including the IV Fluids and Nebulizer.
For example:
If we give IV antibiotic we must mention why we give it vs oral therapy, following
question must be applied:

 Does the patient vomit oral medications?

 Is the patient not responding to oral medication?
 Is the patient in acute emergency and oral medication cannot be given?
 For how many days is the patient’s complaint?

If the attending physician’s prescription includes injections/treatment of more than one dose,
sending of services/bill should be in every visit of the patient. It should not be sent in just one
bill or one day of clinic visit.

Page 3 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

APPROVAL PROTOCOLS AND GUIDELINES

1. Every insurance card of the patient has its approval limit. Any services to be done to the
patient below approval limit are no need for pre-authorization request as per insurance
company protocol.
2. We have to know the approval limit to decide whether to ask for approval or not.
i. Approval Limit Amount
 500SR – minimum approval limit from the insurance companies
 750SR
 1000SR
 2000 SR
 No Approval Limit – These are the patients who fall under VIP or VVIP
classes

SERVICES AMOUNT
Consultation 100
X-Ray 120
Medication 200

Total 420
The above table is an example of patient claims
Situation No. 1: If the patient’s approval limit is 500SR as written in the system and patient’s
insurance card but the total claim is 420SR only, it means that this claim does not need approval.
(Exception to this rule will be discussed later)

Example:

SERVICES AMOUNT
FIRST VISIT
Consultation 100
X-Ray 120
Medication 220

Total 420
Follow-up
Medicine 90

Total 530

Situation No. 2: : A patient comes after three days for follow up and attending physician decided to
give additional medicine worth 90 SR. Now, the total claim cost is 530 SR.

Page 4 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

In this situation, patient comes for follow-up and medicine was added to the previous claim. In the
above situation, the total claim is 530 SR. Approval must be requested for all the previous and current
services. This is very important as it is the cause of high rejection percentage if doctors missed or
forgot about this.

Situation No. 3: If the patient has approval limit of 500 SR, can any medication and/or investigation
within the limit be sent or requested?

No. It is not guaranteed that claim will be approved or paid by the insurance company. The attending
physician must follow the previous rules discussed about medication, investigation, and E.R. services.

Situation No. 4: A patient comes after 15 days and he opens for a new consultation, shall the services
in the prior consultation included in the approval to be sent?

No. If there is new consultation and the follow-up period has been consumed, the patient will start
another approval limit according to his class.

a. Services were given to the patient as the first claim did not reach the approval limit. Then,
approval was done in the succeeding visit (with in follow-up period) but authorization request
was rejected. The attending physician has the right to appeal so that the authorization request
will be approved. In case claim is still rejected, CEO’s decree will take place.

b. Never render services to a patient if there is still no response to the authorization request from
the patient’s insurance company. Let the patient wait outside the attending physician’s clinic.
Exception to this rule is for emergency cases. If authorization request was rejected or partially
approved as per payer’s response and services was already done by the patient, a deduction to
the attending physician will take place or as per CEO’s decree.

1. In general, the following circumstances shall not be covered by any insurance company:
 Off-label therapy or use of a medicine not specified in the SFDA’s approved packaging
label or insert.
 Treatment of a complication of an uncovered condition (e.g. complication of obesity).
 Management of condition due to side effects of an uncovered medicine.
 Prescription of a covered medicine to treat an uncovered condition.
 Work-related injury, unless insurance coverage includes such.

Page 5 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

APPROVAL PROTOCOLS AND GUIDELINES PER CLINIC

DENTAL NOTES
DEPARTMENT
Possible Approval Status from Insurance Companies:
For dental all services
need authorization 1. Approved or Granted: that means all requested services could be
request in all done.
insurance companies
regardless the 2. Conditionally Approved: this means ok for all according to contract
approval limit of the limits and exclusions so you have to know the patient’s coverage.
patient. Consultation, For example if willrequest for crown and the status is conditionally
medicines, x-ray, and approved you have to check first if this patient is covered for crowns
all dental procedures or not
need approval before o If covered it means approved
rendering the services. o If not covered it means rejected

3. For other approval status:

i. Limited Approval: that means the remaining limit of the patient
not enough for the services for example if you send approval for
total of 1000 SR and the remaining limit of the patient is 700
the status of the approval will be limit approval

ii. Partial Approval: that means some items approved, some items
are not so you have to read the payer’s comment carefully to be
sure what are being approved and what are being rejected.

iii. Rejected: that means all listed services required were denied. A
payer’s comment is written in the approval as to what is the
reason of rejection and could explain to the patient.

Remember that each approval has expiration. If patient did not do the
services within validity time, approval request could be renewed by asking
the assistance of insurance approval in-charge, with the approval of DSMC
Insurance Manager.

BASIC DENTAL COVERAGE

 Non-cosmetic Filling (Amalgam or Composite)
 RCT (Root Canal Treatment)
 Extraction (Surgical or Simple)
 Gum treatment
 X-ray (Panoramic X-Ray)
 Medication
 For other services, the attending physician must check for patient’s
coverage (Table of Benefits). Some patients are covered for
orthodontics, some for crowns and bridge and others for implants.
This are just a few polices in each insurance company.
Page 6 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

 Mouth wash, in general, is not covered in insurance companies but if

the institution and insurance company (e.g. Tawuniya) have agreed
code for it, it will be covered.

Addendums:
 All cosmetic treatments are not covered
 If we have approval for Scaling, crown and bridge appliance is not
covered, unless covered by the patient’s insurance policy.
 Teething gel is not covered.
 If there is approval for specific services, it cannot be changed
without changing the approval. For example, if there is approval for
RCT and, the attending physician decided to change the procedure
into composite filling while doing the service. The approval must be
changed even if the approved amount is greater than the new service
to be done.
 Services rendered to the patient should coincide with the
authorization requested and in the DCAF with same tooth number or
medicines.
 It is recommended to do panorama before RCT and surgical
extraction
 Inform immediately the Insurance Department for approved services
not rendered to patients. The non-rendered approved services will be
cancelled as to not consume the patient’s dental benefit.

OBSTETRICS- NOTES
GYNECOLOGY
CLINIC
 For all ANC patients, do approval for all services needed, especially
for the FIRST ANC (Antenatal Care) visit.
 There is maternity protocol that must be followed in all insurance
companies. In general, laboratory tests/visits/medications out of the
maternity protocol will be considered according to the patient
As per general condition subject to prior approval.
instruction regarding  There is no policy coverage for the following:
the acceptance of the o Maternity services if not eligible (single status, daughters)
patient mentioned o Fetal and chromosomal anomaly tests are considered as
before with the screening tests and not part of regular ANC, hence, not
following covered except for Fetal Anomaly Scan in the second
modification. trimester which could be covered and will be considered as
ultrasound of the second trimester.
MATERNITY PROTOCOL:
1st Trimester (0-3 months)
 1 visit every 6 weeks (total: 2 visits)
 Covered services:

Page 7 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

o CBC
o Urine Analysis
o RBS
o Blood group and RH
o Ultrasound (8weeks)
o HBsAg
o Rubella IgG
o Toxo IgG
o HIV Screening
2nd Trimester (4-6 months)
 1 visit every 6 weeks (total: 2 visits)
 Covered services:
 CBC
 RBS
 Ultrasound
2nd Trimester (7-9 months)
 7-8 months: 1 visit every 4 weeks (total: 2 visits)
 9th month: 1 visit every week (total: 4 visits)
 Covered services:
o CBC
o RBS
o Ultrasound
Total number of visits for routine ANC during uncomplicated pregnancy (10
visits).

Note that BUPA will not cover the ultrasound under 8 weeks gestation even
if it is approved. It must be done after 8 weeks of gestation.
 One ultrasound each trimester is covered except in emergency cases,
as long as it is medically indicated like in bleeding or severe lower
abdominal pain or after trauma, etc.
 In routine ANC, insurance companies cover only iron, calcium, and
folic acid supplements, as long as the medicines are registered in
SFDA.
 As mentioned, approval is needed for any service regarding ANC
for each visit except in the following companies.
 BUPA: 1st ANC visit only and in emergencies
 TAWUNIYA: 1st ANC visit only
 GlobeMed: 1st ANC
 Medgulf: 1st ANC
 SAICO: 1ST anc
 MALATH: Every Visit
 For non-pregnant patients, general rules regarding authorization
request should take place as mentioned before.
 Hormonal supplement is covered during pregnancy (e.g.
Duphaston).

Page 8 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

First ANC Visit means that the patient was first seen in DSMC in her
current pregnancy, regardless of services, even if for consultation only.

NOT COVERED CONDITIONS/SERVICES:

 Polycystic ovaries
 Irregular cycle
 Hirsutism
 Sexually Transmitted Diseases
 All kind of vaginal douches even medically indicated.
 All cases of infertility or infertility-related complaints except in very
few policies. It is better to consider it not covered at all.
 Investigation and/or treatment of hirsutism and/or related condition.
 Any plastic minor operation
 Birth control devices or pills
 In general, insurance companies do not cover the assistance or
prevention of conception. All covered investigation done related to
not covered complaints/diagnosis will be rejected or denied. A
request for ultrasound for patients with bleeding will be
covered/approved. Nonetheless, if it is related to folliculometry, it
will be denied/rejected.

INTERNAL NOTES
MEDICINE CLINIC
 Chronic illness treatment coverage is approved under insurance but
insurance companies should be aware that the patient has a chronic
illness prior becoming an insurance card holder. A declaration letter
The most frequent filled by the patient must be done.
seen patient in the  If the patient listed that he or she have no chronic illness, the
internal medicine insurance company will not cover it and affirm it as false declaration.
clinic is the chronic  It is possible that a knowledge about the chronic illness started after
patient the start date of policy as in case the patient discovered accidentally
that he has diabetes after three months of policy period.
 In any case, if there is a patient with chronic illness, either newly
diagnosed or known beforehand, but the patient is new with his/her
insurance company, the attending physician must send approval to
know if insurance company will cover the case or not.
 Chronic medications are costly. Always check patient’s approval
limit and kindly send for pre-authorization request even for one-
month supply if above approval limit.
 The insurance companies will cover one-month supply of treatment
for chronic medication regardless of quantity. For example, if the
patient is diabetic and he will consume three boxes of Diamicron for
one month, we will give all his dose enough for one month. We

Page 9 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

cannot repeat the chronic medication except after 28 days from last
supply period.
 In general, most insurance companies can allow medication
prescription of more than one month but must send approval first to
insurance company.
Attention:
o Check the expiration date of the patient’s insurance card.
Prescribing chronic medication good for one month with two
weeks left prior expiration of card is not allowed. Chronic
medication to be dispensed should be for two weeks only.
(e.g. If a patient consumes four boxes of Diamicron MR
30mg monthly, he shall be given two boxes only in this case)
o For patients who uses one box of medicine a month and
comes in for refill but his card will expire after five days, the
attending physician can give one box. In general, minimum
quantity sufficient until the end of policy is allowed.
 Some insurance companies cover some medical devices such as
glucometer and glucometer strips but pre-authorization is needed.
 All vitamins are covered if registered in SFDA as medicine and
medically indicated with a confirmed laboratory or X-ray.
For example, calcium will be covered if there is low calcium level
confirmed by laboratory result.
 For all upper GIT endoscopy, approval must be secured even if under
approval limit.
 Overuse of medications especially proton pump inhibitors (PPI) is
crucial to insurance companies. Thus, prescription must be regulated
or observed. Uncritical use of PPIs to treat symptoms not caused by
an underlying acid-related disease (e.g. acute gastritis) will lead to
claim rejection.
 Protective medicine must not be used as treatment, only to prevent
complication.
 Treatment of a complication of an uncovered condition will not be
covered.
 Medgulf and Globemed companies need approval for all chronic
condition treated including asthma. Chronic management and any
services, not only medicine, related to chronic condition needs
approval.
 Dealing with First Time Chronic Conditions:
1. Hypertension:
o Ask for last prescription and last investigation
reports.
o If not available check blood pressure if normal
controlled, if normal controlled give the patient his normal
medications based on old prescription.
Follow up Investigations for HTN:
o Lipid Profile first time only later on will be done if

Page 10 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

there are any clinical signs to support doing it.

o Renal Profile “Creatinine & BUN” every 3-6
months.
o Renal U/S only once and repeated if there are clinical
signs to support doing it.
2. Dyslipidemia:
o Ask for last prescription & last investigation reports.
o If not available do lipid profile, then give the
medication he is using.
o If LDL within limits repeat the lipid profile after 6
months, if LDL is high re do after 3 months.
o If the patient is taking statins we will do basic liver
function every 3-6 months .

3. Diabetes Mellitus:
o Ask for last prescription & last investigation reports.
o If not available do RBS or FBS & HBA1C, then give
the medication he is using.
o For follow up FBS will be done monthly and
HBA1C will be done every 3-4 months according to clinical
signs.

4. Hypothyroidism & hyperthyroidism:

o Ask for last prescription & last investigation reports.
o If not available do TSH if not normal do T3 & T4
then give the medication he is using.
o For follow up TSH only every 3-4 months according
to clinical signs.

OPTHALMOLOGY NOTES
CLINIC
 All cases related to error or refraction needs pre-authorization
request as long as there is an agreement contract between the
Ophthalmology clinic insurance companies.
contain eye diseases  Insurance companies cover regular lenses with frames as basic
and error or refraction coverage but as listed in dental also, there is sublimit for it for
example general policy cover frame and lenses up to 400 SR only as
per contract agreement with the insurance companies
 Other classes like VIP and A may cover more or even unlimited
limit so approval must be sent for all cases.
 Some company cover medical contact lenses but in high insurance
classes.
 All lubricant for eye dryness is covered if registered in SFDA.
Page 11 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

 For Medgulf patients: Any intervention procedure to be done to the

patient warrants pre-authorization.

E.N.T CLINIC NOTES

 Ear piercing is covered for female newborn only.
In ENT clinic, in  Ear wash is covered if medically indicated
addition to the  Audiogram is covered if medically indicated.
following points,  The insurance cover the hearing aid up to specific limit like dental
general instructions and optical. it is around 2000 SR per year per policy
for medications must  For Medgulf patients: Any intervention procedure or minor
be followed. procedures to be done to the patient warrants pre-authorization.

PEDIATRIC CLINIC NOTES

 All insurance companies cover vaccination based on MOH
vaccination program granting the scheduled vaccine corresponds to
the patient’s current age. As such, vaccination for two months must
For the pediatric be at given to a patient who is two months old, etc.
clinic, vaccination is  If a patient was delayed in receiving the vaccination, the attending
most significant. physician must mention the reason in the patient’s data (e.g. the
patient was sick, admitted to the hospital, or vaccine is not available
in market). In this case, a delayed vaccination should have a pre-
authorization request from the patient’s insurance company and
mention the child is to receive the vaccine delayed.
 In all insurance companies, except BUPA, a newborn patient can be
treated for a period of 30 days using the mother’s card. Some
policies of Tawuniya can extend up to three months.

Newborn vaccine-BCG and Hepatitis B is a part of delivery package deal.

DERMATOLOGY NOTES
CLINIC
 Any other skin disease, viral, fungal or bacterial, is covered.

NOT COVERED SERVICES

 Off-label therapy, or indication of medicine not specified in the
SFDA-approved drug label
 Preventive treatment
 Treatment of complication of uncovered condition (such as Fucicort
prescription post-laser session, Acne etc)
 All sexually transmitted diseases are not covered.
 All cases of infertility are not covered.
 All cosmetic services are not covered including, but not limited to,
acne, Seborrheic Dermatitis, alopecia/Hair fall, vitiligo,
hypopigmentation/hyperpigmentation, hirsutism, and skin tags.
Page 12 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

Dermatology Medicines:
 There is very little policy covering treatment of non-covered
diseases. Ask the approval of the DSMC-Insurance Manager first.

ORTHOPEDIC NOTES
CLINIC
 In any kind of trauma we must mention that, when the trauma
happened, how the trauma happened and where the trauma happened
 In orthopedic, with fine details about circumstances of the trauma and details of
trauma and injury happened.
fracture are  It’s better to get approval for cast if needed especially in SMALL
the most COMPANIES AND MEDGULF.
frequent case.  The intrarticular injection is covered if medically indicated. Also
 Insurance haylurnic acid injection is covered but the medication must be
companies registered in SFDA and should request for pre-authorization first
cover trauma before rendering to the patient.
if not related  Any vitamin deficiency diseases or illness that needs vitamin supply
to work or are all covered as long it has a confirmed laboratory or x-ray as in
sport injury or the case of osteoporosis.
suicidal  For Medgulf patients: Any intervention procedure or minor
attempts. procedures to be done to the patient such as stitching or intra-
 RTA (Road articular injection warrants pre-authorization request.
Traffic
Accident) is Insurance company will not cover the following conditions:
covered but  Incomplete trauma documentation
needs police
 Use of PPI as prophylactic therapy
report and is
subject to  Work-related condition, unless stipulated in patient’s insurance
approval  Road Traffic Accident (if without Police Report)
 Off-label use of medication

SURGERY/UROLOY NOTES
CLINIC
 Cosmetic surgery is not covered
 Work-related condition, unless stipulated in patient’s insurance
 Road Traffic Accident (if without Police Report)
 Treatment of Sexually Transmitted Diseases and Genital warts
 Follow all the previous rules for medication prescription
 In cases of trauma, the attending physician must mention what,
when, how and where the trauma happened, as mentioned in
orthopedic clinic. If stitching is indicated, approval must be done.
 Treatment of BPH is covered if not related to infertility.
 Pre-operative investigation is a part of the package of the operation
itself. Thus, pre-operative investigation to any patient who will
Page 13 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

undergo operation in another hospital is not allowed.

 For Medgulf patients: Any intervention procedure or minor
operations to be done to the patient warrants pre-authorization
request.

PHYSIOTHERAY NOTES
CLINIC
 All physiotherapy services need approval before any service is
started.
 There is an annual limit for physiotherapy.
All  Only services need pre-authorization request. For consultation, there
physiotherapy is no need for pre-authorization request prior to it.
services need  We must fill the physiotherapy sheet which indicates - the dates of
approval sessions, with patient’s signature, also contain the modules of the
beforehand services used as electrical stimulation, etc…

Page 14 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

INSURANCE COMPANIES APPROVAL BACKGROUND

As general, the biggest insurance companies with market leader are:

1. TAWUNIYA
2. BUPA
3. MEDGULF
This is may cover 80% of the insurance market in KSA.

NAME OF
INSURANCE OVERVIEW
COMPANIES
1. BUPA a. BUPA company work in the field of health insurance only. No any other
income from other kind of, such as commercial insurance, reflect its
behavior with insurance claim.
b. The rejection percent in BUPA is high, thus, must take caution and be
careful with insurance claims. Symptoms and signs must be detailed and
diagnoses must match the services done.
c. The approval limit for BUPA is different from other companies. In
general, the approval is 1000 SR net for clinic services and 1000 SR for
medications in one day. If there is follow up, the patient has a new
approval limit.
NOTE: Remember that this is only in BUPA.
d. The approval in BUPA for dental or optical expires at the end of the
month or end of the card or whichever comes first.
Example:
o The approval in BUPA for DENTAL or OPTICAL will expire
at the end of the month or expiration of the card (which comes
first).
For example, if we have approval on 20th day of March, this
approval will be expired on the 30th day of the same month
(March). But if the insurance card will be expired on the 25th
day of the same month, therefore, the approval will be valid
until the 25th day only.
e. But for any other approval, except dental and optical, the approval
validity is one month or until the end of the policy.
f. Approval is needed for minor operation.
g. Approval for first ANC visit only then follow up maternity protocol. If
patient came for emergency during ANC, send approval.
h. All the instructions mentioned before for insurance company must be
followed in BUPA.

2. Tawuniya a. For Tawuniya, if electronic claim is used, data must be clear. All data
must be in the check-up date, with reference to the date of follow up
(e.g. On January 1, 2018, patient complained of abdominal discomfort).
Maximum of two (2) diagnoses only. If there is extra diagnosis, use it as

Page 15 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

signs and symptoms.

b. For ANC (Antenatal Care), approval must be sent during the first visit
only. Follow maternity protocol afterwards. Sending approval is not
needed in emergencies during ANC.

c. Medgulf a. Most of the polices in Medgulf is class “C” and has approval limit of
500 SR only.
b. There are special approval requirements in this company and are listed as
follows:
o Any minor operation needs approval including stitching and
intra-articular injection.
o Regarding maternity, the company allows a patient to follow-up
ANC with one provider only. Be sure to ask the patient if she did any
approval or investigation in other provider/institution. Approval must be
done for first ANC visit then according to maternity protocol. If the
patient wants to transfer her ANC in our clinic or to another provider, it
is the responsibility of the patient to contact/inform her insurance
company that she would like to transfer her file.
o Approval must be sent first for any chronic condition laboratory
or medication.
d. AXA a. No special instruction
b. ANC approval for every visit and any services including
consultation
e. AL RAJHI a. No special instruction
TAKAFUL b. ANC approval for every visit and any services including
consultation
f. NEXT CARE a. Needs approval for any hormone regardless the cost
b. Needs approval for abdomino-pelvic ultrasound
c. ANC approval for every visit and any services including
consultation
g. GLOBEMED a. No special instruction
b. ANC approval for every visit and any services including
consultation
h. SAICO a. The following is the list of services that needs prior approval:
1. Pregnancies and maternity follow up service, first visit only
2. Dentistry treatment services
3. Examination of eye sight and medical glasses (frames, lenses,
contact lenses)
4. Physiotherapy starting from second session
5. Medicines and investigations of chronic diseases for the first time,
can be approved at a maximum of three months but must not exceed
the policy expiry date.
6. Hormonal analysis
7. Ear piercing for females
8. General medical check up
i. MEDNET a. No special instruction

Page 16 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

b. ANC approval for every visit and any services including

consultation
j. TCS a. No special instruction
b. ANC approval for every visit and any services including
consultation.
k. MALATH CARE a. ANC approval for every visit and any services including
consultation
o Other laboratory tests / visit / medications out of this protocol
will be considered according to the patient condition subjected
to prior approval.
If IgG is +ve, IgM will be covered)

ADDENDUMS

Addendums are the protocols received from the Insurance Company/CCHI to be abided by the
provider for the continuous care to the Insured Cardholders.

1. HIV/AIDS Screening test is part of the ANC Routine for Obstetric patient starting
this July 2019. The approved ANC initial work up (one time service), will be as follows:

 CBC
 Urine Analysis
 RBS
 Blood group and RH
 Ultrasound
 HBsAg
 Rubella IgG
 Toxo IgG
 HIV/AIDS test

Page 17 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: INSURANCE COMPANIES POLICY POLICY NUMBER:

IPP-INS-005
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI CLINIC DOCTORS
Executive Manager

APPROVAL

NAME SIGNATURE DATE

Prepared by: DR. IBRAHIM ELSHOURA

Insurance Manager

Reviewed by: DR. ZAYDOON NADI

DSMC-Medical Director

Reviewed by:

Approved by: DR. SAEED AWDAH ALASIR

DSMC - Chief Executive Officer

Page 18 of 18