Original Author(s)€¦ · Pentacare hospitals/clinics procedure I. Reception / Front Desk...

Original Author(s) Network Manager

Origination Date 1st January 2014

Update date 1st January 2015

Version III – 2015

Pentacare Medical Services L.L.C of 31

Contents

Provider Manual ............................................................................................................... Error! Bookmark not defined.

Pentacare Member Health card .................................................................................................................... 4

Pentacare hospitals/clinics procedure .......................................................................................................... 5

I. Reception / Front Desk Responsibility .............................................................................................. 5

II. Administrative/ Treating Physician/Nurse Responsibility .................................................................. 6

III. Financial Responsibility .................................................................................................................... 7

IV. Visiting Physicians Protocol .............................................................................................................. 8

Pentacare pharmacies procedure ................................................................................................................. 9

Pentacare diagnostic centers procedure .................................................................................................... 10

Pentacare exclusion list .............................................................................................................................. 11

I. General Exclusion ........................................................................................................................... 11

Pentacare pre-approval procedure and indications .................................................................................... 13

I. Pre-Approval Indications ................................................................................................................. 13

2. Outpatient / Diagnostic Procedures................................................................................................... 13

3. Pharmacy .......................................................................................................................................... 13

4. Physiotherapy ................................................................................................................................... 13

II. Verbal Pre-approvals: ......................................................................................................................... 13

III. Written Pre-Approval Procedures ................................................................................................... 14

1. Emergency In-Patient .......................................................................................................................... 14

2. Non-Emergency In-Patient Cases ....................................................................................................... 15

3. Out-Patient Services ............................................................................................................................ 15

Claims submission & reconciliation ............................................................................................................ 16

Procedure for claims submission ............................................................................................................. 16

Procedure for reconciliation ..................................................................................................................... 16

E Claims workflow ....................................................................................................................................... 18

Dubai Essential Benefit Plan ................................................................................................................... 18

Frequently Asked Questions ....................................................................................................................... 20

Network .................................................................................................................................................... 20

PBM / E CLAIMS ..................................................................................................................................... 20

Contact details ............................................................................................................................................. 23


Appendix A – Pentacare claim form sample ............................................................................................... 24

Appendix B – Pentacare Pre-Approval form sample .................................................................................. 25

Appendix C – Pentacare checklist for claim submission ............................................................................ 26

Appendix D – Pentacare invoice sample .................................................................................................... 27

Appendix E – Pentacare reconciliation report sample ................................................................................ 28

Appendix F – DHA Exclusion List ............................................................................................................... 29

Appendix G – HAAD Exclusion List ............................................................................................................ 31


Pentacare Member Health card

Front Side:

Back Side:

Insurance company logo

Member card number

Deductible amount to be

collected from patient

after consultation

Penta Plus/1/2/3/Eco

Group/Policy holder Logo

Expiry Date as indicated

Benefits as indicated

Co –Payment amount to be collected from the patient as per policy


Pentacare hospitals/clinics procedure I. Reception / Front Desk Responsibility

1. Emergency Cases: Top priority is immediate attendance to the patient. After stabilizing the

medical condition obtain Verbal Approval from Pentacare Call Center at 800-73682(PENTA).

Within 24 hours of Verbal Approval Provider should fax to Pentacare at 04 2946448/ email:

[email protected] the duly completed Pentacare Claim form along with the relevant

medical reports and investigation results to justify the services.

2. Non-emergency Cases: After patient arrives at facility, Pentacare card must be verified for its

validity, network category and for any specific indications/ conditions. Provider should check

for patient’s identity against the photo on the card (if available) or against a valid identity card.

The following information on the Pentacare card is to be verified:

(a) Expiry Date: The date that the insured member’s policy benefits and ability to receive direct billing

service at your facility expires. The expiry date is inclusive of the end date. For example: Expiry Date = 31-October-2015

A consultation occurring on October 31, 2015 is inclusive up to 12 midnight. For chronic medication, when the prescribed period is beyond the expiration date, Pentacare

must be billed until the expiry date only. The rest of the medicine has to be billed to the member directly.

Claims sent to Pentacare relating to expired cards will not be paid and will be the Provider’s responsibility

(b) Network: indicates the type of network the provider is entitled to accept

Network Category Entitlement

Penta Plus Providers classified as Penta Plus can only accept Penta Plus cardholders.

Penta-1 Providers classified as Penta-1 can accept Penta Plus and Penta-1 cardholders

Penta-2 Providers classified as Penta-2 can accept

Penta Plus ,Penta-1 and Penta-2 cardholders

Penta-3 Providers classified as Penta-3 can only

accept Penta Plus ,Penta-1, Penta-2 and Penta-3

cardholders

Penta-Eco

Providers classified as Penta-Eco can

accept Penta Plus ,Penta-1, Penta-2, Penta-3 and Penta- Eco

cardholders(( The network is designed as Hospitals for IP services

only /medical centers for OP services only )

If the provider’s name is specified on the card, it means that the provider can accept this card on direct billing regardless of the network category

Some cards can have special conditions/remarks mentioned that the provider must follow. For example: Penta-3 (OP only) IP restricted to Canadian Specialist Hospital, Penta-Eco +IRANIAN HOSPITAL, CEDARS JEBEL ALI HOSPITAL, NMC-DEIRA FOR OP/IP, 10% Co-pay onLab/Diag./Medicines if OP @ Hospitals only, Specialist

mailto:[email protected]


visit allowed after GP referral.

OP only means the cardholder has outpatient coverage only at the mentioned network on the card. IP restricted means (inpatient) coverage is restricted to a specified facility mentioned on the card

II. Administrative/ Treating Physician/Nurse Responsibility

Guidelines for requirements for physical claim form submission (applicable only for providers who will submit physical claims (Northern Emirates))

Section A - Patient Information of the Pentacare Claim form should be completed in detail. (Refer

Appendix C) All fields on the Pentacare Claim form are mandatory. Handwriting must be CLEAR and LEGIBLE. Please ensure that the Membership ID is indicated correctly on the Claim form. It is always advisable

to keep a copy of the card and original Green copy of the claim form at your facility for reference. Insurance company’s field MUST be mentioned in the allocated field. Section B- Treatment Information, Section C- Hospital Information and Prescription part of the

Pentacare Claim form shall be filled by the patient’s treating physician along with the date of the treatment.

Treating physician’s signature is required on the first page of the form and stamp on all claim copies

of this multilayer form. Ensure that Patient’s (or relative for minors) signs the Claim form Check if the medical diagnosis/procedures/services are excluded or require Pre-approval.

Refer to Pentacare Exclusions List, Pre-approval Indications and procedures Pre-approvals a r e required for all outpatient services related to Maternity and for

Physiotherapy services. Refer to Pre-approval Indications section. Authorization code must be indicated correctly on the claim form

Please adhere to the billing, claim submission and re-submission time periods as per agreed contract. Please ensure the date on the Claim Form and the Pre-approval Form are aligned.

The colored claims forms should be attached to the original bills as indicated below:

o For medicines, the original prescription (if any) should be attached to original Yellow copy of the Claim Form –both stamped and signed by the treating physician.

o For investigations, the laboratory/radiology order (if any) should be attached to original Pink copy of the Claim Form- both signed and stamped by the treating doctor. In case, the patient has been referred to another diagnostic facility for part of the investigations, the same should be indicated on the claim forms.

o The original White copy for consultations/ follow-ups should be forwarded to Pentacare along with original bills/ batch of claims and the original green copy of the claim form can be retained by the Hospital or medical center for their records.

For diagnostic procedures that are to be conducted outside the hospital/clinic and fall under the Pre-


approval indications, it is the hospital/clinic’s responsibility to obtain the Pre-approval from Pentacare. The name of the Diagnostic Center you are referring to should be mentioned on the Claim Form and should be in the patient’s designated Pentacare network as mentioned on their Insurance card. For assistance on the list of diagnostic centers enlisted with Pentacare and their network categories, you may call Pentacare at 800-73682(PENTA)

Please provide copy of the written approval (for a service that requires pre-approval) along with a stamped copy of the applicable Pink or Yellow Claim Form to members who are referred to Diagnostic Center and/ or Pharmacy.

All Pathology and Radiology Reports must be signed by a licensed Pathologist or Radiologist

respectively in order to be valid and acknowledged with the submitted Claim.

All pre-approvals for outpatient/investigations/Inpatient procedures are valid for 14 calendar days

from the date of approval. Once the pre-approval validity expires the provider should send a re-approval request to Pentacare along with reason for delay in procedure.

Please provide copy of the written approval (for a service that requires pre-approval) along with a

stamped copy of the applicable Pink or Yellow Claim Form to members who are referred to Diagnostic Center and/ or Pharmacy.

For all trauma/injury/ heat exhaustion cases, please provide detail medical history along with cause of trauma or injury or heat exhaustion.

Medications that are not medically necessary, not medically appropriate, not related to diagnosis and medications not prescribed by the treating physician will not be covered.

Investigations such as but not limited to ECG, EEG, Tympanometry, Audiometry, CTG etc. will be paid only if submitted with graphic recording/typed report (stamped by the physician) or both.

50% discount is to be applied on the 2nd Surgical Procedure when performed at the same sitting.

III. Financial Responsibility For cases that are not authorized or excluded, 100% of all related charges should be collected

from the patient after applying the agreed upon network discount. For eligible/authorized cases, any applicable Deductible Fee/Co-participation Fee/amount

exceeding sublimit must be collected from the patient and the eligible remainder should be billed to Pentacare.

The Deductible Fee is a fixed amount paid by the patient on the Consultation prior to leaving

the hospital/ clinic and will be indicated such as percentage or amount for eg: 20% or AED 25, AED 50, etc. Pentacare will not be responsible in case of failure to collect Deductible Fee from patients.

Co –payment Fee, when applicable, is a percentage paid on Net Price of all services

and Pentacare will not be responsible in case of failure to collect Co-payment from the patient. When applicable as per member policy, Co-payment is applicable on the service as indicated on

the card and should be collected after discount has been applied and deductible collected. Some cards have special conditions regarding Co- payment.

E.g.: 10% Co-pay on Lab/Diag./Medicines if OP at Hospitals only. In such cases, follow the instructions written on the card and collect the Co-payment amount against the specified services only. Application of Co-payment will be monitored by Pentacare.


Pentacare is only responsible for paying those coverable services as listed on the agreed tariff list and covered as per the Provider’s Manual. Please list the rendered individual service tariffs on the Invoice Form as they are stated in the Agreement Tariff List, indicating the Gross Price, agreed Discount percentage, Net Price and applicable Deductible and Co-payment Fee due from the member. (Refer Appendix D for Pentacare Invoice Sample)

For the coverable billed services that are not available on the tariff list, a waiting period of 5 working

days will be given to the Provider to respond to price negotiations prior to Technical Denial of the Claim Form being issued by Pentacare. Please forward an email to [email protected] with formal request in order to avoid future Claim Rejections.

Please adhere to the Pentacare Invoice Format structure (Appendix D) and ensure including Service

Name, Gross Price, Discount % and Net Price for each service item rendered as per agreed contract and Deductible Fee and Co-payment Fees when applicable.

Reasons for claim denial or partially paid claims will be clearly stated in the Pentacare Claim Payment

Report which will be provided with payment. All claims with history of trauma/ injury/ heat exhaustion, should have the cause mentioned on the

claim form and must be pre-approved (refer Pre-approval indications) by Pentacare Call center 800-73682(PENTA), before dispensing the medicines

IV. Visiting Physicians Protocol Network Visiting Physician and Network In-patient Facility: Subject to Pre-authorization from

Pentacare.

Out-of-network Physician and Network In-Patient Facility: The network In-patient facility should provide Pentacare with the Visiting Physician License Copy. Pentacare will pay the Network In- patient facility (Hospital) the agreed Surgery Fee as per Provider Tariff List and out-of-network Surgeon as per agreed Surgeon Fee on the Tariff List of the In-patient Facility Provider Tariff and the remainder/excess to be collected from the patient.



Pentacare pharmacies procedure

Guidelines for requirements for physical claim form submission (applicable only for providers who will submit physical claims (Northern Emirates)

Pharmacist should check the Pentacare card, yellow copy of the claim form (should include date, stamp and signature of physician) and original dated prescription.

Pharmacist should verify the card for its validity, member network category and for any specific

Indications/ conditions.

The member’s Pentacare card should be verified with the member’s other valid personal ID.

The Expiry Date is the date that the insured member’s policy benefits and ability to receive direct

billing service at your facility expires. The expiry date is inclusive of the end date. For example: Expiry Date = 31-October-2015 A consultation occurring on October 31, 2015 is inclusive up to 12 midnight. For chronic medication, when the prescribed period is beyond the expiration date, Pentacare must be billed until the expiry date only. The rest of the medicine has to be billed to the member directly. Claims sent to Pentacare relating to expired cards will not be paid and will be the Provider’s responsibility.

It is the pharmacy personnel’s responsibility to check the member’s card and complete any missing

information in “Section A- Patient Information” of the Claim Form.

Check that all fields in the Claim form are completed CORRECTLY AND CLEARLY by the

hospital/clinic. Check for date of treatment, Physician’s signature and stamp on Claim form.

Check if the prescribed medicines are excluded or require Pre-approval (Refer Exclusion List and

Pre-approval indications) 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. For eligible/authorized cases, any applicable Deductible Fee and/or Co-payment amount, after

applying the discount, must be collected from the patient and the remaining amount should be invoiced to Pentacare.

Original dated prescription should be attached to submitted claim. Medications and dosage should be

clearly mentioned on the yellow claim form or original prescription, signed and stamped by the treating doctor.

Medications that are not medically necessary, not medically appropriate, not related to diagnosis and

medications not prescribed by the treating physician are not coverable. A copy of the prescription can be provided to the patient upon request.


Pentacare diagnostic centers procedure Guidelines for requirements for physical claim form submission (applicable only for providers who will submit physical claims (Northern Emirates)

The member will present a signed and stamped copy of the Pink Claim Form by the treating physician along with copy of the Pre-approval Form if required.

Verify card for its validity, member network category and for any specific indications/conditions

The member’s Pentacare card should be verified with the member’s other valid personal ID.

The Expiry Date is the date that the insured member’s policy benefits and ability to receive direct

billing service at your facility expires. The expiry date is inclusive of the end date. For example: Expiry Date = 31-October-2015

A consultation occurring on October 31, 2015 is inclusive up to 12 midnight.

For chronic medication, when the prescribed period is beyond the expiration date, Pentacare must be billed until the expiry date only. The rest of the medicine has to be billed to the member directly. Claims sent to Pentacare relating to expired cards will not be paid and will be the Provider’s responsibility.

Check that all fields in the Claim Form are completed CORRECTLY and CLEARLY by

thehospital/clinic. It is the provider’s responsibility to check the member’s card and complete any missing information in “Section A- Patient Information” of the Claim Form.

Check if the diagnostic procedures are excluded or require Pre-approval. (Refer to Pentacare

Exclusion List and Pre-approval indications section)

If the requested diagnostic procedures require Pre-approval, (Refer Pre-approval indications section) it is the responsibility of the hospital/clinic referring the member to seek a Pre-approval. The copy of the signed and stamped original Pink Claim Form and copy of written approval must be forwarded to your diagnostic center to proceed with the service.

For cases that are not authorized or excluded, 100% of all related charges should be collected

from the patient after applying the agreed upon Network Discount.

For eligible/authorized cases, any applicable Deductible Fee and/or Co-payment amount, after applying the discount, must be collected from the patient and the remaining amount should be invoiced to Pentacare.

Outpatient investigations that require pre-approval (Refer Pre-approval Indications section) are

valid for 14 calendar days from the date of approval. Once the pre-approval validity expires the provider should send a re-approval request to Pentacare along with reason for delay in performing the investigation.

All Pathology and Radiology Reports must be signed and stamped along with date by a licensed

Pathologist or Radiologist respectively in order to be valid and acknowledged with the submitted Claim.

Investigations such as but not limited to ECG, EEG, Tympanometry, Audiometry, CTG etc. will be

paid only if submitted with graphic recording/typed report (signed/stamped by the physician) or both.


Pentacare exclusion list

I. General Exclusion

1. Cosmetic, plastic or reconstructive surgery and medical, unless necessitated by an accidental injury

occurring while the insured is covered under Group Medical Plan.

2. Medical conditions such as but not limited to corns, warts, acne, hair and skin pigment disorders,

cosmetic or plastic surgery consultations including deviated nasal septum.

3. Psychological and psychiatric illness, mental retardation, attention deficit disorders, developmental

delays or abnormalities, whether physical, psychological, emotional, behavioral, speech or

intellectual, precocious puberty, hearing difficulties, etc

4. Suicide, Self-inflicted/intentional injury while sane or insane.

5. Substance abuse, addiction or alcoholism.

6. Services or treatment in any long term care facility, rehabilitation center , Spa, hydro clinic, rest cures,

sanatorium, home care, nursing home, or home for the aged, periods of quarantine or isolation.

7. Home visits unless it is an emergency as defined in the Policy definitions (subject to pre-approval)

8. Routine medical examinations & tests including but not limited to preventive checkups, well baby

checks ,screening tests, prophylactic treatment ,vaccinations, inoculations, medical certificates and

medical examination for residence, employment or travel.

9. Radiation contamination.

10. Injury or illness resulting from natural disasters, insurrection or war, declared or undeclared, or as a

result of a riot, strike or civil commotion.

11. Professional sports injuries and hazardous sports injuries.

12. Prosthesis, corrective devices and durable medical appliances that is not surgically required including

hearing aids

13. Congenital diseases or malformations, genetic disorders, developmental disorders.

14. Infertility tests and treatment, sexual dysfunctions, sterility and contraception.

15. Sexually transmitted diseases, AIDS & HIV

16. Desensitization and tests for allergy

17. Anorexia, obesity, insomnia, hair loss, baldness, hirsuitis

18. Genetic engineering and cloning

19. Organ, tissue, cell, blood and bone marrow donation.

20. Diseases designated by the WHO and /or national law as epidemic.

21. Alternative therapies, such as homeopathy , acupuncture, osteopathy, ayurvedic ,chiropractic,

chiropody etc;

22. Workman’s compensation, work related injuries (subject to approval)

23. Experimental or unproven treatment or drug therapy

24. Consultations, tests or treatment of speech and voice problems.

25. Charges for any service or supply that is not medically necessary such as but not limited to

registrations fees, dietician consultation and consumables.

26. Investigation or treatment /medication for which pre-approval is required and has not be obtained.

27. Senility and age related conditions.

28. Treatment required as a result of medical malpractice.

29. Vision screening /Refraction Errors

30. Allergies screening tests/ panel tests are not covered.


I. Pharmacy Exclusions:

1. Fertility, infertility, related medicines /agents.

2. Sexual dysfunction medications.

3. Hearing aids, eyeglasses, contact lenses, contact lens solutions, and accessories.

4. Psychotherapeutic medications (tranquilizers, sedatives, weakness or fatigue medications etc.)

5. Appetite stimulants, appetite suppressants, dietary preparations, weight loss medicines.

6. Oral hygiene, non-medicated lozenges, oral sprays, dental/gum related medicine/products etc

7. Contraceptive medicines and products.

8. Cosmetic products, acne preparations & medications, lotions e.g calamine, moisturizers,

sunscreens, skin lightening agents, masks, face cleansers, antiseptics, alcohol, waxsol etc. 9. Enzyme preparations, anti-oxidants ,liver tonics

10. Herbal & homeopathic preparations, preventative medicines

11. Oral rehydrating solutions

12. Soaps ,shampoos, cleansers ( medicated and non –medicated)

13. Hair and scalp preparations

14. Vaccination/ Immunizations

15. Immunotherapy e.g Bronchovaxone, Elidel cream etc

16. Smoking cessation, substance abuse medications.

17. AIDS /HIV, STD related medicines

18. Outpatient prescribed or non-prescribed medical supplies such as Collars, supports, braces,

crutches, gauze, insulin needles, belts, wraps, stockings ,external prosthesis/devices,

glucometers, pumps, durable medical equipment, crepe bandage, bandages ,disposables,

glucose strips , lancets etc

19. Pain balms, rubefacient, joint maintenance products, non-medicated preparations and

medicated preparations except when medically indicated as per diagnosis

20. Castor oil, Cod Liver oil , Eucalyptus oil, Karvol etc

21. Hormone replacement therapy other than thyroid

22. Diaper /Nappy rash cream, formula, baby supplies

23. Eye lubricants, Artificial tears, Liquifilm ,Dura tears

24. Normal Saline (Drops & Sprays) except when prescribed for Nebulization and for babies up to

3 years of age.

25. Laxatives except when prescribed for underlying medical conditions such as anal fissure,

hemorrhoids etc. Osmotic laxatives are NOT covered. Anti-Diarrheal (Kaptin Suspension are not

covered)

26. Vitamins, minerals and supplements except when prescribed, not medically appropriate, not

related to the diagnosis, medications not prescribed by physician.

27. Medications given for treatment of or related to an excluded medical condition as per General

Exclusion List

28. Urine Alkalinizer such as Urocit-K, Epimag etc

I. Diagnostic Exclusions:

1. Fertility, Infertility related tests and procedures. 2. AIDS/ HIV related tests and procedures (including pre-operative &maternity ) 3. Preventive tests and checkups 4. Screening tests and procedures. 5. Employment related check ups 6. Any test not prescribed by a medical doctor licensed by MOH/DHA/HAAD 7. Any test done after the Diagnosis (Consultation) of condition under the General Exclusion list 8. Over investigation that are not medically appropriate and not related to medical condition 9. Tests for Allergy


Pentacare pre-approval procedure and indications

I. Pre-Approval Indications Pre-approval is always required for the following:

1. In-Patient/ Same Day Procedures

All In-patient admissions All Daycare/short stay admission Major and minor surgeries All emergency cases to be notified within 24 hours from date of admission

2. Outpatient / Diagnostic Procedures

All work related injuries, trauma, heat exhaustion cases (mentioning detail history with cause of the trauma/ injury/ heat exhaustion) is mandatory.

All out-patient surgical procedures, dressings Maternity related services (investigations, ultrasound and pharmacy, all maternity services are subject

to approval irrespective of gross amount) All investigations with a gross amount above AED 500 (please note: investigations refer to all

diagnostic procedures of laboratory, radiology, ECG etc. put together) Special diagnostic procedures such as MRI, CT scan, Contrast studies, EEG, PET scan,

Endoscopies, Echocardiography, Treadmill test, Angiography, Mammography, etc. All emergency cases to be notified All consultations, investigations and treatment by a Visiting physician Optical/ Dental Certain policies may have a higher pre-approval limit and our providers will be informed of the

same through written communication. o Certain Policies which has pre-defined approval limit will be always communicated to

all our providers through written communication ( For eg: Metlife Policy for OP services the pre-approval limit is AED 250 Gross( including Lab , Diagnostic, Pharmacy) For Pharmacies, this pre approval limit will be applicable only if they will submit physical claims (Fujairah, RAK,UAQ and Sharjah providers )

3. Pharmacy

Medications with a gross amount above AED 500 More than 2 months medications even if the gross amount is below AED 500 Maternity medications and supplements Certain policies may have a higher pre-approval limit and our providers will be informed of the

same through written communication. Vitamins will be covered based on supportive documents /medical necessity.

4. Physiotherapy

Outpatient physiotherapy sessions

II. Verbal Pre-approvals: Definition:

The verbal pre-approval is meant to provide formal decisions over the phone on medical services to be provided on emergency or urgent basis. Decisions delivered by Pentacare may be either a complete/ partial approval, guarded or a denial.


Emergency Medical Services: Are acute medical services (medical and/or surgical) that needs to be delivered immediately where delays may result in jeopardizing patient’s life and functions

Urgent Medical Services: Are services (diagnostic and/or therapeutic) that need to be provided

immediately to patients who are waiting at provider’s facility. Indications for Verbal Pre-approvals

Providers can seek verbal pre-approval only for the following medical services: Maternity services Dental/ optical services Pharmacy services Emergency Room Services Admissions related to medical or surgical emergencies (in this case provider can initially obtain a

verbal pre-approval and after 24 hours of notification should obtain a written formal approval from Pentacare)

Verbal Pre-approval Procedure

Providers call Pentacare on the 24/7 Call Center number 800-73682(PENTA) To accelerate the delivery of pre-approvals, providers are requested to provide Pentacare agent

with all needed clinical/ technical information related to beneficiary. Pentacare agent notes down the request details and subsequently delivers a decision

(complete/partial approval, guarded or denial) as per beneficiary’s policy terms and conditions. At the end of each phone call, Pentacare agent delivers a pre-authorization code that provider

shall indicate clearly on the Pentacare claim form. (please note: name of the agent alone without the pre-authorization code will not be accepted)

Pentacare Verbal Pre-authorizations are not valid or applicable in the followings circumstances:

In case of Non-Emergency/ Elective medical services, providers have to apply for written

pre-authorization by sending (via fax and/or e-mail) the “Claim Form” duly filled along with all the relevant clinical and technical information/documents to Claims Center as per the agreed procedures (refer to Written Approvals Procedure)

In case providers request an Extension of Inpatient Stay whenever it is required, they shall apply

for a written pre-approval 24 hours before the end of approved length of stay. Providers shall submit all necessary clinical reports justifying their request (i.e. an updated medical progress report, results of latest clinical investigations, the interim bill). If providers fail to comply, Pentacare and patients are not held responsible of any delays.

III. Written Pre-Approval Procedures Pre-approvals are valid for a maximum of 14 calendar days from the date of approval.

Once the pre-approval validity expires the provider should send a re-approval request to Pentacare along with reason for delay in procedure.

1. Emergency In-Patient

Immediately attend to the patient Stabilize the condition. Obtain a verbal pre-approval within 24 hours by calling the Pentacare Call Center at 800-73682

(PENTA) for admission and managing the condition. Provider should fax the duly completed Pentacare Claim Form to Pentacare at 04-2946448 or email: [email protected], along with

mailto:[email protected],


relevant medical reports and test results to justify the service being requested for further evaluation of approval request.

The Claim Form and any supporting documents such as the Pre-approval document, Medical Reports, Discharge Summary and Invoices MUST be attached when submitting Claims for

Payment.

2. Non-Emergency In-Patient Cases

Send the Claim Form and any supporting documents (medical reports) by fax to Pentacare at 04- 2946448 or email:[email protected]

Wait for the written reply. Pentacare will reply (approval or denial) by email or by faxing the same Claim Form within 24

hours- 48 hours. The Claim Form and any supporting documents as the Pre-approval document, Medical Reports,

Discharge Summary and the Invoices MUST be attached when submitting Claims for payment.

3. Out-Patient Services

For out-patient services that do not fall under emergency or urgent medical services such as MRI, CT scan,etc.send the Claim form and any supporting documents (medical reports) by fax to Pentacare at 04-2946448 or email: [email protected] and wait for the written reply.

Pentacare will reply (approval or denial) by email or by faxing the same claim form with the approval/ denial stamp within 24-48hrs.

The Claim Form and any supporting documents as the Pre-approval document, Medical Reports, and the Invoices MUST be attached when submitting Claims for payment.



Claims submission & reconciliation (applicable only for providers who will submit physical claims (Northern Emirates)

Procedure for claims submission

Claims must reach Pentacare no later than 30 days from date of service or as indicated in the contract for eligibility of payment.

Claims should be submitted along with the following documents (Refer Appendix C):

o Original Pentacare Claim Form fully completed and signed & stamped. All fields must be filled.

o Original Yellow copy of claim form for medicines along with prescription, original pink copy of claim form for investigation( laboratory/ radiology) with corresponding reports - all forms should have date, stamp and signature of treating physician

o The original itemized detailed invoice o Copy of the written approval for Inpatient claims/ Outpatient investigations or Verbal pre-

authorization code (for medicines) if the claim falls under preapproval indications. Copies of all related investigation results, medical reports, original prescriptions, discharge summaries, etc.

Claims received by Pentacare after the Contract agreed submission or re-submission period will

not be paid and will be the Provider’s responsibility.

Investigations such as but not limited to ECG, EEG, Tympanometry, Audiometry, CTG etc. will be paid only if submitted with graphic recording/typed report (stamped by the physician) or both.

All pathology / radiology reports must be dated, signed/ stamped by a licensed Pathologist /

Radiologist in order to be evaluated and paid.

Pentacare would like to ensure correct payments are made to the Diagnostic Provider where the service has been rendered. Please mention the name of the Diagnostic Provider where the Diagnostic Test will be done when requesting for Pre-approval.

50% discount is to be applied on the 2nd Surgical Procedure performed at the same sitting.

Please submit each Batch of Claim Forms with the following:

o The Original Itemized Invoice (must include Name of Service, Gross Price, Discount %, Net Price as per Contract)

o Detailed Statement Of Account.

Ensure the same correct information (Date, Patient Name, Membership ID, Invoice Number, Charges) are stated on the Claim Form, Invoice, Detailed Statement of Account.

Payments are provided as per the terms of the Network Agreement. Cheques will be dispatched

along with Claim Payment Report.

Procedure for reconciliation

All reconciliations must reach Pentacare as indicated in the contract. Re-submit the missing documents/ justification as requested in the Reconciliation Report and

include a photocopy of the Claim Forms along with a Reconciliation Report (Sample Format


provided in Appendix E).Please use the same Provider Batch Number on each Reconciliation

Report and do not mix Batches.

Therefore, for a few Claims of different Batches, segregate the Claims according to Batch number using a new Reconciliation Report for each Batch.

After evaluation, Pentacare can return/reject Claims due to the reasons as will be stated clearly on the Pentacare Medical Claim Payment Report

The Claims Pentacare has evaluated and rejected are due to the following reasons:

i. Technically Denied (Missing Document/s): The claim lacks one or more supporting documents

that are required. Example: Lab report/results, Missing written pre-approval copy, etc. ii. Partial Denial: A portion of the claimed amount is denied as per the terms & conditions of the

policy. Reason of denial will be mentioned in the Claim Payment Report. Example: Laboratory test not justified.

iii. Full Denial: The entire claimed amount is denied as per the terms & conditions of the policy.

Reason of denial will be mentioned in the Claim Payment Report. iv. Final Denial: These are denials after re-evaluation of re-submitted claims. The decisions are final

and resubmissions are no longer considered.


E Claims workflow

Dubai Essential Benefit Plan


Pentacare is one of the approved unconditional TPA in Dubai and approved by DHA for the management of DHA Essential Benefit Plan with PI (participating Insurance). This plan is accessible to only Penta ECO providers in Dubai Emirates Please find below card samples for EBP plan:

20% co pay on

Lab /Diagnostic

20% co pay

on

consultation

30% co pay on

Medicine

10% co pay on

IP/consultation/M

edicine


Frequently Asked Questions Network

Question: What is Penta Eco Network?

Answer: Providers classified as Penta-Eco can accept Penta Plus,Penta-1, Penta-2, Penta-3 and Penta- Eco

cardholders(This network is designed such as Hospitals is only for IP & Clinics/ medical centers is for OP only

)

PBM / E CLAIMS

Question: What is PBM / e Rx?

Answer: In contemplation with DHA mandate dated on 30th December 2013, all medical providers should

request electronic approvals from payer/TPA (Pentacare) for all prescriptions (either paper or electronic form).

The portal of this electronic system is PBM (http: // www.pbmlink.com//)

Question: How to activate PBM system?

Answer: The medical providers who are in network list of Pentacare need to send email request for activation

of PBM at [email protected] with license specifications (DHA/HAAD/MOH)

Question: How many days it will take for activation of PBM?

Answer: It will take 3-5 workings days upon receipt of the email request of activation.

Question: How do we submit claims through PBM?

Answer:

Non-Integrated: The providers who are using non-integrated system and processing through all transactions

through PBM portal http: // www.pbmlink.com// are entitled for real time claims submission through system.

Automated PBM approval code will be generated and the system will process these claims for submissions

to Pentacare.

Integrated: The providers who are using integrated system are entitled for claims submissions at end of month

in form of e claims to Pentacare

Question: If the PBM e reference number is not available with the member, can we still dispense medicines

through PBM?

Answer: Yes, if member does not have PBM e reference number (From Doctor) still PBM active pharmacy

can dispense medicines through PBM System.

Question: How do we know the eligibility of the member, in case the PBM system shows non valid member?

Answer: In such cases where the PBM system shows the member is not eligible but he is holding valid

membership ID, please contact our 24 * 7 helpline number which is 800-73682(PENTA).

http://www.pbmlink.com/


http://www.pbmlink.com/


Question: What steps to be followed in case of PBM system is down?

Answer: When PBM network is down, please contact our 24*7 helpline number which is 800-73682(PENTA).

Question: What are e claim / Electronic claims billing?

Answer: E claim is a statement from health care provider presented to insurance company /TPA for evaluation

and settlement of services through electronic portal. Electronic claims billing is the process by which a health

care provider electronically submits a bill, or claims, to a Payer /TPA (Pentacare) for rendering medical

services.

Question: What are Payer Id‘s for e claims processing?

Answer: DHA /Dubai Providers

Pentacare’s ID/ Receivers ID

TPA013 PENTA CARE MEDICAL SERVICES LLC

Payer’s ID: For payer Id’s kindly contact us on [email protected]

HAAD/ Abu Dhabi & Al Ain Providers

C008 PENTA CARE MEDICAL SERVICES LLC

Payer’s ID: For payer Id’s kindly contact us on [email protected]

Question: Do we need to provide additional information about injuries/ burns cases and how?

Answer: Yes, you need to provide the cause and type of injury (work related or other) /burns in the

“Observation Table” while uploading e claims and on physical claim forms (applicable only for providers who

will submit physical claims (Fujairah, RAK,UAQ and Sharjah. You can also upload the appropriate ICD code

specifying the Place of occurrence (E-Codes).

Question: How do we provide the name of the Injection while uploading e claims?

Answer: There are two ways where you can provide us these details.

You can provide the name of the Injection in the “Observation Table” while uploading e claims

You can provide the name as additional activity along with CPT of Injection administration charges (

Intramuscular(IM) / Intravenous (IV)/ Subcutaneous )

Question: How can we resubmit fully /partially rejected services through e claims?

Answer: Upon receipt of Remittance advice, you can re-upload the rejected services with the requested

details.

Types of resubmissions: There are two types of resubmissions.

1. Correction Fully rejected claims should be uploaded as correction type, like, entire claim were rejected due to incorrect member id, or supported documented was not submitted.

2. Internal complaints Partially rejected claims should be uploaded as internal complaints type, like for example, few of the activities were rejected in particular claim and only those activities will be resubmitted as internal complaints.


For any further assistance, you can contact us at [email protected]

Question: Can we upload two different e claims using the same file name?

Answer: No, file name should be unique for each uploading submission/ resubmission

Question: If the Pentacare member is not carrying the valid membership ID but only photocopy or scanned

copy of card, can we accept the member?

Answer : No , you cannot accept the members without valid membership ID.



Contact details

For Pre-approvals, please call 24/7 Call Center: 800-73682(PENTA)

For Administrative Issues and to Order Claim Forms, please call the reception on 04-2946443

Fax: 04-2946448

For network related issues / inquiries

Website: www.pentacare.net

Pre-approval Inquiries: Email to [email protected]

Network Inquiries / Issues: [email protected]

Claims Resubmission/ Reconciliation: [email protected]

General Inquiries: [email protected]

Mailing Address for Claim Submission:

Pentacare Medical Services LLC Business point Building, Office # 201

Deira, Behind Nissan Showroom

P.O. BOX 184508

http://www.pentacare.net/


Appendix A – Pentacare claim form sample

S. No: 078122 PENTACARE TEL: 04-2946443; FAX: 04-2946448, HELPLINE 056-7142828 /800-PENTA (73682)

SECTION A · PATIENT I N FORM ATION

I nsurance company: ---------------- Organization:------------- - -

-- Member Name : ------------- - -- Tel. No.:

Membership I D :--------------D.O.B:

Provider Name :-----------------Fax No.: -----------

SECTION B .TR EATMENT I NFOR M ATION 0 on Ch ronic Och ronic 0 Materni t y Ooema l Ooptical

Complaint/Symptom

Date first noticed

Provi sional Diagnosis

Tests!freatment

Referral(if needed)

-Ph-y-sic-ian-

S-ta-mp-.s-ig-na-tu-re -an-d -Da-te-

-- - ---Ph-ys-iC-ia-n c-od-e -----

----PC-

M-

C-

o-de-an-d-St-am-p-- - -

SECTIO N C· HOSPITAL I NFORMATION (ln case of refferral) PLEASE f.lLL ITHIS SECTIO\\'JIE."'l REFEMRIG' TO Our PA"r!E..''T PROCEDURE ON lfOSPITALIZATIO:O..

Hospital/Laboratory/Radiology Cent re Name: _

Ind ication of R eferral

Date of Referral

AUTHORIZATION CODE

----

P-hy-•c•-an -SU-im-p a-nd -Da-te- - ---

---- --Ph-ys-ici-an-C-ode- ------

PRESCRIPTION

PRICE I S. No : 0 7 812 2

DATE:

------ - ------- ----

Pharmacy Scamp

Pharma6n Cod PO!Code

l l I j TOTA L PRICE f POWER OFATTOR NEY

I b) aulhonu lhepO)iK. HospWo;wtofikaclll••(orllltde.. ICnon m) balfandl c:Uftfii'1Dth.u lbeabo\c DealMIIINe\-.IUlXIIlfi.II.._IJtbc'rapy ••J• c•to-lt)'lbc doctor I buflt)'--.,.uu)

Hmacad.Kp.atNl MPdtl)-u,.:.w... ,.,..,_.,.Ofuy cOer .,ho hti oded .rd.c&l teniCft 10-or •)' drprndanu 10 (\lnud! 111y and all u:tform.tiOII..,tb n:a•rd 10 any nwdo.;al h1Jt0f)'a. wd.caJ tc.dll Of ILl lotniCflo Mel coptr$ of all

Aortelefu COp)' oflllu •1.1lklnutt01t a./1 be 0011'u cffecto'l'e Md •al!d 111 U.OllJinal

Da te :

Signa ture of Insu red Person or Cla i mant - --- - - - --- - - - (10 be signed after the doclor has filled the fo nn)


Appendix B – Pentacare Pre-Approval form sample


Appendix C – Pentacare checklist for claim submission

CHECKLIST FOR CLAIMS COMPLETION

SR. # Points to be verified & Approved

1. By the Receptionist before Patient leaves the Providers Office

2. Batch of Claim Forms is re-checked by the Billing Person before Claim Submission

1 All Forms have the Provider’s Name

2 All Forms have the Date Of Service

3 All Forms have the Pentacare Member ID

4 All Forms have the Patient Name

5 All Forms have the Diagnosis and Actual Cost

6 All Forms have the Patient’s Signature

7 All Forms have the Doctor’s Signature

8 All Forms have the Doctor’s Stamp

9 Pentacare Card Copy is ATTACHED to Claim Form

10 Pre-Authorization Form is ATTACHED to Claim form or Verbal Pre-Authorization code is

provided (when applicable)

Pre-Authorization is valid 14 calendar days from Date of Approval from Pentacare

11 Medical/ Procedure Report is ATTACHED (when applicable)

12 All Radiology or Pathology reports must be signed by a licensed Radiologist or Pathologist

13 Original Prescription with Date is ATTACHED to Claim Form

14 All Prescriptions have the Treating Doctor’s Stamp and Signature

15 All investigation results are ATTACHED to Claim Form

16 Itemized Invoice is ATTACHED to Claim Form

17 Name and Member ID of the Patient on the Invoice & on the Claim Form are same

18 Invoice Form must cover the following columns:

Service Description

Net Price

Discount %

Net Price

19 Deductible or Co-payment is applied (when applicable) & reflected in the Invoice

20 Batch of Original Claim Forms is Submitted as per the Contract Submission Period

Name & Signature of Billing person approving Final Check on the Claims

Please Provide Detailed Statement of Account along with the Invoices


Appendix D – Pentacare invoice sample

Pentacare Medical Services INVOICE

Providers Name: Patients Name:

Providers Address: Patient’s Member ID:

Providers Contact No.: Invoice Date:

Invoice Number:

S. No. Service

Code

Service

Description

Quantity Gross

Amount

Discount

%

Discount

Amount

Patient’s Share Net

Amount

Deductible Co-Pay

1

2

3

4

5

6

7

8

9

10

Notes: Total

(AED)

28 | P a g e

Appendix E – Pentacare reconciliation report sample

Provider Name

Pentacare Batch No.

S. No. Claim

no.

Member

ID

Patient

Name

Treatment

Date

Invoice

no.

Claimed

Amount

Approved

Amount

Denied

Amount

Provider

Remarks/

Justification

29 | P a g e

Appendix F – DHA Exclusion List

1. Healthcare Services which are not medically necessary

2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.

3. Home nursing; private nursing care; care for the sake of travelling.

4. Custodial care including

(1)Non-medical treatment services;

(2)Health-related services which do not seek to improve or which do not result in a change in the medical

condition of

the patient.

5. Services which do not require continuous administration by specialized medical personnel.

6. Personal comfort and convenience items (television, barber or beauty service, guest service and similar

incidental services and

supplies).

7. All cosmetic healthcare services and services associated with replacement of an existing breast implant.

Cosmetic operations

which are related to an Injury, sickness or congenital anomaly when the primary purpose is to improve

physiological functioning

of the involved part of the body and breast reconstruction following a mastectomy for cancer are covered.

8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control

programs, services, or

supplies.

9. Medical services utilized for the sake of research, medically non-approved experiments and investigations

and pharmacological

weight reduction regimens.

10. Healthcare Services that are not performed by Authorized Healthcare Service Providers.

11. Healthcare services and associated expenses for the treatment of alopecia, baldness, hair falling, dandruff or

wigs.

12. Health services and supplies for smoking cessation programs and the treatment of nicotine addiction.

13. Any investigations, tests or procedures carried out with the intention of ruling out any foetal anomaly.

14. Treatment and services for contraception

15. Treatment and services for sex transformation, sterilization or intended to correct a state of sterility or infertility

or sexual

dysfunction. Sterilization is allowed only if medically indicated and if allowed under the Law.

16. External prosthetic devices and medical equipment.

17. Treatments and services arising as a result of hazardous activities, including but not limited to, any form of

aerial flight, any kind

of power-vehicle race, water sports, horse riding activities, mountaineering activities, violent sports such as

judo, boxing, and

wrestling, bungee jumping and any professional sports activities.

18. Growth hormone therapy.

19. Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids.

20. Mental Health diseases, both out-patient and in-patient treatments, unless it is an emergency condition.

21. Patient treatment supplies (including for example: elastic stockings, ace bandages, gauze, syringes, diabetic

test strips, and like

products; non-prescription drugs and treatments,) excluding supplies required as a result of Healthcare

Services rendered

during a Medical Emergency.

22. Allergy testing and desensitization (except testing for allergy towards medications and supplies used in

treatment); any

physical, psychiatric or psychological examinations or investigations during these examinations.

23. Services rendered by any medical provider who is a relative of the patient for example the Insured person

himself or first

degree relatives.

24. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary

during in-patient

treatment.

25. Healthcare services for adjustment of spinal subluxation.

26. Healthcare services and treatments by acupuncture; acupressure, hypnotism, massage therapy,

aromatherapy, ozone therapy,

homeopathic treatments, and all forms of treatment by alternative medicine.

30 | P a g e

27 All healthcare services & treatments for in-vitro fertilization (IVF), embryo transfer; ovum and sperms

transfer.

28. Elective diagnostic services and medical treatment for correction of vision

29. Nasal septum deviation and nasal concha resection.

30. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related investigations,

treatments

31. Healthcare services, investigations and treatments related to viral hepatitis and associated

complications, except for the treatment and services related to Hepatitis A.

32. Birth defects, congenital diseases and deformities.

33. Healthcare services for senile dementia and Alzheimer’s disease.

34. Air or terrestrial medical evacuation and unauthorized transportation services.

35. Inpatient treatment received without prior approval from the insurance company including cases of

medical emergency which were not notified within 24 hours from the date of admission.

36. Any inpatient treatment, investigations or other procedures, which can be carried out on outpatient

basis without jeopardizing the Insured Person’s health.

37. Any investigations or health services conducted for non-medical purposes such as investigations

related to employment, travel, licensing or insurance purposes.

38. All supplies which are not considered as medical treatments including but not limited to: mouthwash,

toothpaste, lozenges, antiseptics, milk formulas, food supplements, skin care products, shampoos

and multivitamins (unless prescribed as replacement therapy for known vitamin deficiency

conditions); and all equipment not primarily intended to improve a medical condition or injury,

including but not limited to: air conditioners or air purifying systems, arch supports, exercise

equipment and sanitary supplies.

39. More than one consultation or follow up with a medical specialist in a single day unless referred by

the treating physician.

40. Health services and associated expenses for organ and tissue transplants, irrespective of whether

the Insured Person is a donoror a recipient. This exclusion also applies to follow-up treatments and

complications.

41. Any expenses related to immunomodulators and immunotherapy.

42. Any expenses related to the treatment of sleep related disorders.

43. Services and educational programs for handicaps.

31 | P a g e

Appendix G – HAAD Exclusion List

Healthcare Services, which are not medically necessary

All expenses r e l a t i n g to dental treatment, dental prostheses, and o r t h o d o n t i c treatments. (Dh 1,500 minimum coverage and co-payment Dh 50 maximum)

Domiciliary care; private nursing care; care for the sake of travelling.

Custodial care includes o Non-medical treatment services; or o Health-related services which do not seek to improve or which do not result in a change in

the medical condition of the patient.

Services which do not require continuous administration by specialized medical personnel.

Personal comfort and convenience items (television, barber or beauty service, guest service

and similar incidental services and supplies).

Healthcare Services and associated expenses for replacement of an existing breast implant. Cosmetic operations which improve physical appearance and which are related to an Injury, sickness or congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body. Breast reconstruction following a mastectomy for cancer is covered.

Surgical a n d non-surgical treatment for obesity (including m orb id obesity), and any other weight control programs, services, or supplies.

Medically non-approved experimental, research, investigational healthcare services, treatments, devices and pharmacological regimens.

Healthcare Services that are not performed by Authorized Healthcare Service Providers, apart from Healthcare Services rendered in a Medical Emergency

Healthcare services, treatments & associated expenses for alopecia, baldness, hair falling, dandruff or wigs.

Supplies, Treatment and services for smoking cessation programs and the treatment of nicotine addiction.

Non-medically necessary Amniocentesis

Treatment, services and surgeries for sex transformation, sterility and sterilization

Treatment and services for contraception

Treatment and services related to fertility / sterility (treatment including varicocele /polycystic ovary / ovarian cyst / hormonal disturbances / sexual dysfunction).

Prosthetic devices and consumed medical equipments, unless approved by the insurance company

Treatments and services arising as a result of hazardous activities, including but not limited to,

any form of aerial flight, any kind of power-vehicle race, water sports, horse riding activities, mountaineering activities, violent sports such as judo, boxing, and wrestling, bungee jumping and any professional sports activities

Growth hormone therapy.

Costs a s s o c i a t e d with h e a r i n g tests, v i s i o n correct ions , prosthetic devices or hearing and vision aids.

Mental Health diseases, in-patient a n d out-patient t r e a t m e n t s , u n l e s s the condition is a transient mental disorder or an acute reaction to stress.

Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, diabetic

test strips, and like products; non-prescription drugs and treatments, excluding such supplies required as a result of Healthcare Services rendered during a Medical Emergency).

Preventive services, inc lud ing v a c c i n a t i o n s , immunizations, allergy t e s t i n g a n d desensitization; any physical, psychiatric or psychological examinations or testing during these examinations.

Services rendered by any medical provider relevant of a patient for example the Insured person and the Insured member’s family, including spouse, brother, sister, parent or child.

Original Author(s)€¦ · Pentacare hospitals/clinics procedure I. Reception / Front Desk...

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Transcript of Original Author(s)€¦ · Pentacare hospitals/clinics procedure I. Reception / Front Desk...