Claims Management
The end-to-end claims management cycle is digitized from members’ eligibility checking to service provision, case management, claims adjudication and payment settlement. We ensure better cost containment measures and unparalleled patient's experience.
A. Utilization Management
An Accelerated and Well-Monitored Process
- Online application, CareGate, integrated with the regulators’ hubs “eClaimLink”, "Shafafiya" and "Raiyati”, allowing healthcare providers to instantly verify members eligibility and submit claims.
- Automating most of outpatient coverage decisions based on 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 areas of abuse through our advanced expert system.
- Concurrent reviews to ensure that the most appropriate treatment is administered while containing cost.
- Case Management aiming at controlling cost of specific cases while ensuring the proper level of care to insured members.
Enhanced Patients’ Experience
- SMS notification to inform patients about the coverage decision.
- 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.
- Adjudication of claims based on policy rules, and validation of medical necessity through the Medical Rules Engine.
- Medical audit by specialized medical officers reviewing flagged claims.
- Quality assurance over data consistency and integrity, detecting any possible errors prior to claims closing.
C. Third Party Accounting
- Timely settlement capabilities, whenever applicable by the regulator, with highly flexible reporting options accessible by payers, facilitating the payment and reconciliation cycle.
- Monthly reconciliation with providers allowing them to review adjusted claims and confirm balance.
