Claims Management
The end-to-end claims management cycle is digitized from member eligibility verification to service provision, case management, claims adjudication, and payment settlement. This ensures stronger cost containment measures and an unparalleled patient experience.
A. Utilization Management
An Accelerated and Well-Monitored Process
- Our online platform, CareGate, is integrated with regulatory hubs “eClaimLink”, “Shafafiya”, and “Raiyati”, enabling healthcare providers to instantly verify members eligibility and submit claims
- Most outpatient coverage decisions are automated through a robust business, policy-related, and medical rules engine.
- Fast turnaround time for manual approval requests handled by GlobeMed.
Constantly Evolving Cost Containment Measures
- Real-time detection of medical, pharmaceutical, and coding discrepancies, misuse or potential abuse through our advanced expert system.
- Concurrent reviews to ensure the most appropriate treatment is administered while maintaining cost efficiency
- Case management designed to control cost of specific cases while ensuring the proper level of care for insured members.
Enhanced Patients Experience
- SMS notifications to inform patients about coverage decisions.
- Automatic safety checks and alerts based on patients’ medical conditions.
- Minimized patients waiting time at healthcare facilities.
B. Claims Adjudication
- Automatic price adjustment based on provider contractual agreement.
- Claims adjudication aligned with policy rules, with medical necessity validated through the Medical Rules Engine.
- Medical audits conducted by specialized medical officers to review flagged claims.
- Quality assurance processes ensuring data consistency and integrity by detecting potential errors before claim closure.
C. Third Party Accounting
- Timely settlement capabilities, in full compliance with regulatory requirements, supported by flexible reporting options accessible to payers, streamlining the payment and reconciliation cycle.
- Monthly reconciliation with providers allowing them to review adjusted claims and confirm balances.
