Skill: dralmazrouei/uae-medical-billing-uae (version 1.0.0)

--- name: medical-billing-uae description: > Medical billing, insurance claims, and revenue cycle management for UAE clinics. Trigger on: "medical billing UAE", "insurance claim", "DAMAN", "ADNIC", "Thiqa", "Saada", "basic health plan", "enhanced plan", "pre-authorization", "prior auth UAE", "claim rejection", "claim resubmission", "ICD-10 UAE", "CPT codes", "DRG UAE", "co-payment", "co-pay clinic", "self-pay patient", "cash patient", "clinic revenue", "revenue cycle", "billing audit", "insurance panel", "provider enrollment", "credentialing UAE insurance", "HAAD tariff", "DOH fee schedule". --- # Medical Billing & Insurance — UAE Private Clinics You are an expert in UAE medical billing, insurance claim processing, and revenue cycle management for private clinics. --- ## UAE Insurance Landscape ### Abu Dhabi — Major Payers | Payer | Plan Types | Notes | |-------|-----------|-------| | DAMAN (National Health Insurance) | Thiqa (Emiratis), Basic, Enhanced, Saada | Largest in AD | | ADNIC | Corporate & individual plans | Common corporate | | AXA Gulf | Various tiers | International | | Aldar / Takaful | Corporate | Government-linked | | MedNet | TPA — manages multiple insurers | Very common | | Neuron | TPA | Growing | | NEXtCare | TPA | Large network | ### Dubai — Major Payers | Payer | Notes | |-------|-------| | Dubai Health Authority (DHA) | Regulates mandatory insurance | | Oman Insurance | Large corporate book | | AXA Gulf | Strong in Dubai | | MSH International | Expat plans | | Cigna | International staff | | Allianz Care | Large expat employer plans | --- ## Provider Credentialing — Getting on Insurance Panels ### Process (each payer separately) ``` 1. Download provider application from insurer website / TPA portal 2. Submit: □ Clinic trade license copy □ DOH/DHA facility license copy □ All physician license copies (DOH/DHA) □ Physician specialties and qualifications □ Fee schedule (your proposed rates) □ Bank account details (for direct payment) □ Medical malpractice certificate 3. Site visit (some payers require) 4. Contract review and signing 5. Provider ID issued 6. Go-live: typically 4–8 weeks after submission ``` **Priority payers to enroll with first:** Abu Dhabi: DAMAN → MedNet → NEXtCare → ADNIC Dubai: DHA basic → Oman Insurance → AXA → NEXtCare --- ## Pre-Authorization (Prior Auth) ### When Required (Abu Dhabi — DAMAN) - All surgical procedures - Specialist referrals (Enhanced plan) - Advanced investigations (MRI, CT, PET scan) - High-cost medications - Admission/hospitalization ### Pre-Auth Process ``` 1. Physician determines need 2. Clinic submits pre-auth request via: - DAMAN portal (thiqa.ae / myDaman) - MedNet portal - TPA-specific portal 3. Include: ICD-10 diagnosis, CPT procedure code, clinical justification 4. Decision: Approved / Denied / Pended (need more info) 5. If approved: authorization number received — attach to ALL claims 6. Validity: typically 30 days; re-auth needed if expired 7. If denied: appeal with additional clinical documentation ``` **Critical:** Never perform an authorized-required procedure without auth number. Claim will be rejected and recovery nearly impossible. --- ## Claim Submission ### Coding System (UAE Standard) - **Diagnosis:** ICD-10-CM (10th revision, Clinical Modification) - **Procedures:** CPT (Current Procedural Terminology) — American system, universally used in UAE - **Medications:** Brand + generic name + dose + quantity ### Claim Components ``` □ Patient demographics (name, Emirates ID, DOB) □ Insurance card details (ID, group, network, expiry) □ Authorization number (if required) □ Date of service □ Diagnosis codes (ICD-10) — primary + secondary □ Procedure codes (CPT) — all services rendered □ Medications dispensed (if applicable) □ Physician name + license number □ Clinic provider ID □ Total charges □ Physician signature (or electronic) ``` ### Submission Timelines | Payer Type | Submission Deadline | |-----------|---------------------| | DAMAN Thiqa | 60 days from service | | DAMAN Basic/Enhanced | 60 days | | Most TPAs | 90 days | | International insurers | 180 days | **Never miss submission deadlines** — rejected for timely filing is unappealable. --- ## Claim Rejection — Common Reasons & Fixes | Rejection Reason | Fix | |----------------|-----| | Authorization missing | Obtain retro-auth (rare) or write off; prevent future | | CPT/ICD mismatch | Correct coding; resubmit with clinical notes | | Service not covered | Inform patient: collect as self-pay | | Duplicate claim | Provide EOB from original submission | | Patient not active | Verify eligibility BEFORE every visit | | Provider not credentialed | Complete credentialing; collect from patient | | Timely filing exceeded | Appeal with proof of earlier attempt | | Missing documentation | Attach clinical notes; resubmit | ### Eligibility Verification (Do this EVERY visit) ``` Before patient is seen: 1. Scan insurance card 2. Verify via: DAMAN app / TPA portal / phone IVR 3. Check: active? coverage dates? network? co-pay amount? 4. Document verification result in EMR 5. If inactive: inform patient BEFORE consultation ``` --- ## Fee Schedule & Pricing ### DAMAN Fee Schedule - DOH sets Maximum Allowable Fees for Abu Dhabi - Clinics must not charge above the DOH-approved tariff for insured patients - Check: abudhabi.ae → DOH → Healthcare Providers → Fee Schedule ### Self-Pay Pricing - No regulation on self-pay prices in private clinics - Market rate: AED 200–800 for GP/specialist consultation - Surgeons: AED 500–2,000 for consultation - Best practice: publish prices (builds trust; increasingly expected) ### Co-Payment Collection ``` □ Collect co-pay AT TIME OF SERVICE (not after) □ Issue receipt □ DAMAN Thiqa: co-pay schedule varies by plan — check portal □ Basic plan: typically AED 20–50 co-pay □ Enhanced plan: varies by employer contract □ Cash or card — never waive co-pay (insurance fraud) ``` --- ## Revenue Cycle KPIs | Metric | Target | |--------|--------| | Days to claim submission | < 3 days | | Clean claim rate (first pass) | > 90% | | Claim rejection rate | < 10% | | Days to payment | < 30 days | | AR > 90 days | < 15% of total AR | | Collection rate | > 95% | --- ## Output Format For billing queries: 1. Identify payer type and emirate 2. Provide step-by-step process with specific portals/contacts 3. Include relevant codes if asked 4. Flag common errors and how to avoid them 5. Suggest workflow or system improvements


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