Contents
Introduction
New Claim
Eligibility Check
Benefits types
Services types
Prescribing Doctor
Prior Approval Request
Claim Process
Introduction
The i*care system is a claim processing system for the use of Out-of-Hospital services such as consultation, ambulatory, dental and pharmacy.This system has the capability to run an eligibility check on the adherent, generate a summary of the benefits and restrictions related to the plan, handle prior approval requests separately while processing claims in its full length cycle.
New Claim
This section entitles the user to enter a new claim or search an existing claim once the patient seeks a medical service at any health care provider associated with MedNet Liban or GlobeMed Ltd. Upon logging unto the system, click “New Claim” on the main menu bar on the left. The Eligibility section appears.
Eligibility Check
In this section, the user must enter the adherent’s identification records for the system to run an eligibility check and therefore can generate the benefit details of the adherent and a claim form (UCAF), if needed.
Note The provider can choose to run only an eligibility check in order to view the adherent’s records and coverage details on the system. Therefore, this step can be run separately at any time on any adherent seeking medical records.
Figure 1
Control / Description / ActionSearch option 1 / A search option that allows the user to look up the adherent by the following identification numbers:
Individual #
Staff #
ID #
Note: This option is mainly used, besides eligibility check, for new claim entry. / Choose the required search identification, enter the number and hit Enter or click Next.
Note: Card scanning option can be used alternatively and the individual number is filled automatically.
Search Option 2 / Another search option that can be used alternatively to the first search option, to look up an existing claim on the system, or to add new items to an existing claim.
You can search an existing claim by the followings:
MCN# It is a group number of multiple claims. This case currently applies in Saudi.
Claim # It is an existing claim number that needs to be looked up.
Invoice # It is an existing invoice number that needs to be looked up.
Note: In case of MCN, you can add a new claim under an existing MCN according to certain criteria pre-defined by the administrator such as duration, provider etc… / Choose the required search identification, enter the number and hit Enter or click Next.
Prescription Key / Prescription key is a number used to refer to a posted claim from one provider to another. / Enter prescription key for posted transactions.
Note: this option is only used for posted transactions.
Chronic
Maternity
Other / Claim type can be specified. “Other” is checked by default.
Note: This option is for record purpose only. / Choose type of claim in any of these check boxes.
Adherent / Name of the adherent will be displayed here upon entering his identification or a claim.
Consulting Doctor / This field shows a list of available doctors in case of a polyclinic.
Note: in case of only one attending physician, this field will only display the name of the physician. / In case of a polyclinic, choose attending physician from the list.
In case the consulting doctor is not in the list, there is an option to create a new doctor within the list. In such case, select “Create a doctor” in the list, and then fill in the doctor entry form.
Note: in case of a new doctor creation, the new doctor name will show in the claim form but it will not be saved until the claim is submitted. A notification email will then be sent to the network department to create the new doctor under the corresponding SSNumber.
View Benefit Details / A link is provided to view a summary of benefits details (coverage description, policy information, general exclusions, coverage details) / Click on this link and a window opens to display the benefit details (See Appendix I)
Generate New Claim Form / This option prints out a medical claim form (or UCAF) to be filled out by the attending physician.
A medical claim form is sometimes required by the attending physicianto record medical conditions and the service(s) required for the patient.
Note: this option will only display in case the provider is a doctor or a polyclinic. / Click this option to generate the medical claim form (See appendix II).
Edit
/ An Edit icon is provided on top of the section to allow user to edit entry. / Click the Edit icon to edit entry and enter your modification.
Close Eligibility
/ A link placed at the bottom of the page to close the eligibility page and go back to the home page. / Click Close Eligibility link at the bottom of the page when finished with the eligibility check.
/ A Next button is provided to continue further down the process by filling out a claim. / Click Next button to continue filling out a claim.
Benefits types
This section displays the benefits types related to the policy and to the provider using the system. The available benefits on the system are the followings:
Prescription Medicine
Doctors Visit
Optical
Dental
Ambulatory
Figure 2
The user must check the type needed for the claim and click Next to proceed with the claim process.
Note usually, a provider has one or two benefits displayed in this section unless it is a polyclinic or a multi-services medical center.
Services types
In this section, a list of medical services related to the type of benefits claim chosen before, is displayed. Check the one(s) that apply and click Next to proceed to the following section.
Figure 3
The list of services is filtered according to the chosen benefits in previous step. For instance, Ambulatory benefit will display the applicable ambulatory services such as lab, ultrasound etc… In case of Prescription Medicine Benefit type, only the service of pharmacy will be displayed and selected by default. In case of a doctor visit, the service type will be either ‘generalist’ or ‘specialist’.
Note the Services section can be controlled by the provider and therefore this section can be optional, required or invisible. A skip button is displayed if this section is set to be optional for the provider.
Prescribing Doctor
In this section, choose the prescribing doctor. Choose the specialty from the list and enter the doctor first or last name, then click the search icon. A search result window appears (figure 5) matching the search criteria. Choose the doctor and close the window.
Note this section only appears in case the provider is a hospital, a lab, a medical center or a polyclinic. In addition, the Prescribing Doctor section can be controlled by the provider and therefore this section can be optional, required or invisible. A skip button is displayed if this section is set to be optional for the provider.
Figure 4
Prior Approval Request
In this step, the user can choose among 2 choices: Prior approval request or Claim process.
Figure 5
In case the claim contains only items that require prior approval submission, the provider might only need to submit a prior approval request to our help desk prior to any claim submission.
Note The term “Items” is used under various benefit types and it is translated according to the category of each type of benefit applied in the claim. For instance, items under ambulatory are specialized medical services that fall under ambulatory. The same applies to dental and optical benefit types. On the other hand, items under Prescription medicine (pharmacy) are considered medicines.
Note Close Eligibility link is used in case the user needs to check only the eligibility of the patient, like we said earlier.
Click the Prior Approval Request and the following section appears.
Figure 6
In this section, user can select diagnosis (optional) and then choose the items for which prior approval request is needed in order to be fully processed.
Note You can always choose to enter a full claim or see the benefit details of the adherent by clicking on any of the corresponding links on top of the page.
Diagnosis
In this section, you can choose the diagnosis from a universal list of diseases. Enter a keyword in the search box or press the search button to open the search listand choose from the look-up window the applicable diagnosis (figure below). This list can be displayed in general terms by choosing “short list” option or in detailed tree format by choosing “complete list” option. It can also be displayed in both languages: English and Arabic.
In addition, you can select one or multiple diagnosis in a claim. You can also choose to delete any diagnosis entry record by clicking the delete button (-).
Note The diagnosis section is usually optional and a predefined value of the diagnosis can be also set by the provider and thus there is no need to look up the diagnosis.
Figure 7
Control / Description / ActionSearch PA Items
Select Service / A list of services for which prior approval request is needed. These services are the ones selected in the previous step by the user.
Note: if a selected service from the service section does not appear in this list, that means that there is NO item under this service that needs prior approval. / Click the drop down list to display the services.
Item Description / A search box for item description. / Enter a lookup word for the item to look for and press the search icon.
Item Code / A search box for item code. / Enter a lookup item code for the item to look for and press Enter or the search icon.
Note: you can enter several codes separated by a comma to look up multiple items at one hit.
Co-Insurance Code / A search box for co-insurance code / Enter a lookup co-insurance code for the item to look for and press Enter or the search icon.
Currency / A currency display according to the policy.
Search Icon / A search icon that opens a screen of the items list (figure10)that matches the search criteria entered in the following fields:
Item Description
Item Code
Co-Insurance Code / Press the search icon after entering your search criteria.
In the example below, we entered “Brain” in the item description and we obtained all items that relate to ‘Brain’ in the search list.
Control / Description / Action
Prior Approval Items
Description / A display of the chosen item description. / You can scroll up and down the arrows to display all description of the item
Quantity / A display of quantity of the item. Default value is 1. / You can modify the quantity by entering directly into the box.
Delete icon
/ 2 delete icons are displayed:
-One delete icon to empty basket, which means it deletes all items at one time. This icon is placed right next to quantity label on the table header.
-One delete icon to delete the corresponding item entry record. This icon is placed right next the item record line. / Click any of the delete icons, if needed.
Rejected Item
/ In case the entered item is rejected, the rejected icon appears next to the item record and the quantity will show as ‘0’.
Questionnaire icon
/ A questionnaire icon is displayed if a questionnaire is provided for the corresponding item in order to facilitate the online approval process.
If this icon is displayed, it is mandatory for the user to fill out the questionnaire in order for the system to generate the online approval process.
If this icon is not displayed, that means the item has no questionnaire related to it and thus the user can directly submit the prior approval request to the help desk. / Click on the questionnaire icon to display a set of questionnaire related to the chosen item. The questionnaire comes in normal view or tree view (see figure 8 & 9).
This questionnaire, if answered, facilitates the approval process online, sometimes without the recurrence to the help desk.
3 decisions might be taken after responding to the questionnaire:
Item is rejected claim is stopped and there is no need to refer to the help desk.
Item is approved claim is processed into the system and there is no need to refer to the help desk. However, a message will appear requesting the user to submit the necessary documents to be submitted with the claim as a proof record.
Prior Approval Claim requests prior approval from the help desk and a prior approval request will be sent when submitting the claim. In case if any supplemented documents are needed, a message will appear informing the user to submit the necessary document with the claim.
After filling out the questionnaire, the system displays a message informing the user of the decision taken on the processed item (see figure 10)
Accepted Item
/ Upon submitting a questionnaire, if an item is accepted, then the accepted icon will display next to the item record on the claim form.
Additional Information / An entry text box for any additional information on the claim. / Enter any additional information that may be needed on the claim.
Submit Transaction
/ This button submits the claim and updates the database according to the decision taken.
If claim is rejected claim is not processed but it is saved into database.
If claim is approved claim is processed as normal.
Prior Approval Prior approval request is sent to the call center. In this case, an email is sent to the call center agents informing them about the claim number and sales slip so that they can process the prior approval request by approving or rejecting it. / Click this button to submit the claim (approved or rejected) or to submit a prior approval request.In the latter case, the prior approval request will be then saved under “Claims awaiting prior approval”.
Cancel Transaction
/ This button cancels the transaction and thus disregards all entry data. / Click this button to cancel the transaction.
Figure 8 – Questionnaire (normal view)
Figure 9 – Questionnaire (tree view)
Figure 10 – Decision Approved.
Upon submitting the prior approval request, the following screen displays to capture the invoice/claim numberthe provider may need to enter and to enter/update the adherent mobile number, if applicable.
You may need to enter one invoice/claim number for all items entered by checking the corresponding option.
Click the submit button when finished.
Figure 11
Note this submission window may vary by provider according to an MCN flag set previously. A provider may choose to process by invoice number, claim number or by MCN rule.
Claim Process
In case the user needs to process a regular claim that requires the lookup of all medical services on the database, he will need to choose the full claim process. Claim process is a regular claim cycle that may process all types of items including the ones that require prior approval.
After selecting the benefit type, related services and a doctor (if applicable), as shown in the previous steps, click on “Claim Process” to process your items.
Figure 12
The following page displays.
Figure 13
Consultation
In case of a doctor visit (cases such as doctor’s clinics), a Consultation section appears on top of the claim entry form that allows doing the followings:
Figure 14
-Charge a consultation fee.
-Post a prescription Order.
-Post a consultation to another specialist.
Charge a Consultation Fee
In case a doctor wants to charge a consultation fee, he will need to select the service from the drop down box (generalist or specialist) then click on “With Charge” button to add the consultation fee in the claim entry form below.
Figure 15
Figure 16
The doctor can then go to the consultation service entry and enter the fees and any discount, if applicable.
Note in case the doctor does not want to charge a consultation fee, he can either delete the consultation entry (if previously entered) or just choose not to select “With Charge” button.
Prescription Order
In case the doctor wants to make a prescription order (to a lab or a pharmacy for example), press “Post Prescription” and the following form opens. In this form, the doctor can fills out the prescribed items needed for the patient and then print out a prescription order form to be dispensed at a provider’s place.
Figure 17
Figure 18
Control / Description / ActionPrescription Order
Select Service / A list of services to which a doctor may need to make a prescription order.
This selection is optional and it is used to filter the items look up by service. / Click the drop down list to display the services and choose the one that applies.
Item Description Code / A search field to look up the item by description or code. / Enter a keyword for the item description or code to look for and press Enter.
A window opens with the search results matching the search criteria.
Select the required item and click close. The item will displays in the prescription order form below.
In case of a medicine, you need to also enter the dosage and frequency and then hit the (+) sign to add it to the form.
Provider / Provider entry field. This option is used in case the doctor needs to post the prescription order to a specific provider. In this case, he can enter the name of the provider here. / Click on the search icon to look up a provider by name or code.
A look up screen displays and you can enter your search criteria and hit enter or the search icon. A provider list displays and you can choose the provider to add it on the Prescription Order Form.
Diagnosis / A diagnosis entry field (optional).
This option is used in case the doctor wants to show the diagnosis on the prescription order form. / Enter a keyword for the diagnosis or select the search button to choose from a diagnosis list.
Item / A display of item description. / This field is populated with the chosen item.
Signa / This field is used only for the prescription medicine to show the prescription dosage and frequency.
Quantity / A display of quantity of the item. Default value is 1. / You can modify the quantity by entering directly into the box.
Delete icon
/ A delete icon to delete the corresponding item entry record. / Click on the delete icon to delete corresponding item entry record line.
Sign / A pharmacy sign is displayed for the medicine item.
Save / This button saves the claim and submits the prescription order into the system.
A print button will display to allow you to print the prescription form in PDF format (figure 19).
This prescription order has a prescription key and it can then be taken to a provider within the network in order to dispense the claim. The prescription key is therefore used to access the claim order from the provider’s site (Lab, pharmacy etc..) / Click this button to save and submit the prescription order unto the system.