Member Guide. Essence Of Care...

Transcription

1 Member Guide الدانة Premier Essence Of Care...

2 Welcome Valued Saudi Enaya Members

3 It is our pleasure to have you become a valued member of Saudi Enaya. We consider it an honor that you have chosen us to be your health care partner. Our aim is to provide you with the best services and products that meet with your needs. We invite you to read this membership guide carefully. It contains all of the information that will help you to reach a better understanding of your membership, since it provides essential information regarding your health care benefits. This guide will help you to make use of all quality services from Saudi Enaya and to understand your full range of benefits. Please contact us for any further information: Phone In KSA Outside KSA care@saudienaya.com Online Mail P. O. Box 3528 Jeddah Kingdom of Saudi Arabia Fax Address Jeddah, Saudi Arabia, Tahliya Street, First Floor, A.G.Alesayi Building Note We kindly advise you to save these contacts on your mobile phone for our instant assistance to be available at your fingertips.

4 This guide applies to the following Saudi Enaya products and offers different territorial limits: الدانه Premier Territorial Limits: KSA & Worldwide I (Worldwide) or Worldwide II (Worldwide excluding USA, Canada, Europe and UK). زمرد Enhanced Territorial Limits: KSA & Worldwide I (Worldwide), or Worldwide II (Worldwide excluding USA, Canada, Europe and UK). ياقوت Classic Territorial Limits: KSA & Home Country only فيروز Care Territorial Limits: KSA only. These products are compliant with the regulations set forth by the Council of Cooperative Health Insurance (CCHI) and have been designed to provide you with: Choice Security Ease of use Peace of mind The products cover all mandatory eligible healthcare expenses for you and your dependents as well as additional extras depending on your level of cover. A Guide to Your Membership We have prepared this guide to help you grasp the concept of being a Saudi Enaya member and to understand your membership benefits as well as your responsibilities. This guide should be read in conjunction with the Table of Benefits that you receive with this guide. Membership Card With this package you will be receiving Saudi Enaya Cards for yourself and your eligible dependents. These cards will allow you to access available services at our designated network of hospitals and clinics (Please refer to the enclosed list of our network providers). Any time you need to visit one of our network providers you need to show your Saudi Enaya membership card, as it shows your membership details. In addition to membership card, please submit your National ID to the staff of the network provider as it is requested for member validation.

5 Valed Membership card details Your Membership Number This is your Enaya membership number الدانة Premier Shaik Abdul Arif Juffali Brothers Policy Number.8888 National ID: Co-Pay OPD: 20% max up to 100 SR. Card NO: Staff NO: 1007 Expiry Date YOB Type Gender Matemity for Co-insurance This is the amount you will be paying directly to hospital/clinic on every out-patient visit. 31/12/2012 Expiry Date Your health coverage is valid until this date with Saudi Enaya X Suite Room Room Type This will be your room category during hospitalization. M N Maternity Sign Y means maternity is covered and N means not covered. Membership card issue number To know more about Saudi Enaya please visit our website. These are our customer service contacts available 24 / 7 Membership card lost In case you lose your membership card kindly contact Saudi Enaya customer service. Saudi Enaya will provide you with a replacement card within 24 hours and it s subject to fees.

6 Saudi Enaya Member Services Member assistance around the clock (24/ 7) Customer Service contact details are located on the back of your membership card. Our professional and bilingual staff are available to provide the best specialized assistance as follows: Guidance and assistance with the selection of providers Information on your health care benefits Coordination of emergency assistance Response to all your inquiries Online Authorization Saudi Enaya s objective is to provide prompt services to all members. Our Network Providers will be able to access our system via the Saudi Enaya Online Provider Portal for the following: View member eligibility View Table of Benefits Send authorization request View authorization status Receive approvals SMS Services Our instant message service will send text messages to your mobile phone for the following: Pre-Authorization request receives by Saudi Enaya Saudi Enaya replies to the authorization request To update you with the latest information

7 Network Provider Saudi Enaya has developed a comprehensive network across the whole Kingdom with Primary Health Care facilities, General Hospitals as well as Specialized / Referral Hospitals. All providers are accredited by CCHI and have been chosen to provide you with the best available services. Note: Saudi Enaya recommends that you obtain an appointment prior to your provider visit in order to avoid long waiting times. A copy of the Network list is included in the membership package and available online on our website. For more details please contact our customer service. Direct Billing & Reimbursement Direct Billing For all the providers in your network (according to the selected product) Saudi Enaya guarantees that you can receive treatment on a direct billing basis. This means that Saudi Enaya will pay for all services rendered to you (within the range of coverage chosen). You will only have to pay your out-patient co-insurance (according to the selected product) directly to the provider.

8 If you require services from any provider outside your network as per your table of benefits, you are allowed to proceed on cash basis and submit your invoices for reimbursement, as explained below. Reimbursement You can utilize services outside of your designated Network Provider, by paying cash for these services and forwarding the invoices to us for reimbursement. The amount will be reimbursed to you as per your product specifications. Please refer to the enclosed Table of Benefits for more details. All Reimbursement Claims must be submitted with the following original documentations: Saudi Enaya Reimbursement form completed and signed. Detailed medical report filled out by your treating doctor along with his signature, date and stamp. Itemized invoices Prescriptions, if applicable. Please Note: Reimbursement claims must be received no longer than 30 days after the date of treatment for services within KSA and 60 days for services availed outside KSA. Processing and settlement of your reimbursement claim will take 14 working days upon the receipt of the claim along with required documentation. Investigation results of any laboratory/ diagnostic reports, if applicable

9 PRE-APPROVAL What is Pre-Approval? Saudi Enaya requires your network provider to contact us to gain approval for a particular treatment or service. This is done to ensure that: You are eligible for the treatment or service under your policy benefits. The proposed treatment or service is medically necessary. The proposed treatment or service is within the reasonable and customary charges of comparable network Providers. There is enough remaining benefit limit on your membership to cover the treatment or service cost.

10 Prior Approval and Notification Requirements Inpatient Services All Inpatient Hospitalization & Day Cases (Medical & Surgical) Admission for Emergency cases Out Patient Services requiring Approval Requires Approval No Approval required, Saudi Enaya should be notified within 24 hours of admission. Out Patient Services Dental & Optical Services, Boys Circumcision & Girls Ear Piercing for new baby born, Chemotherapy & Radiotherapy, Psychiatric Cases, Renal Dialysis, And Hearing Aid. Other Out Patient Services (Excluding Consultation & Medication) Premier الدانة : Does not require Approval. Enhanced زمرد : Requires Approval if total amount exceeds SR 1,000. Classic ياقوت : Requires Approval if total amount exceeds SR 750. Care فيروز : Requires Approval if total amount exceeds SR 500. Medication Acute Cases: Does not require prior approval. Chronic Cases: Treatment for more than one month requires Approval. Maternity Requires Approval for first visit only. Physiotherapy First session does not require Pre-approval, following sessions require approval.

11 Saudi Enaya will not cover claims arising from: 1. Intentional self-inflicted injury. 2. Sicknesses resulting from abuse of some medicines, stimulants or tranquilizers, or from use of alcohol, narcotics and similar substances. 3. Cosmetic treatment or surgery unless necessitated by a bodily injury not excluded under these exclusions. 4. General checkups, inoculations, drugs or preventive measures not required for medical treatment covered under this policy (excluding preventive measures determined by the Ministry of Health, such as vaccination, maternity and child care.). 5. Pregnancy and delivery treatment of a woman identified in her contract as unmarried. 6. Treatment received by a beneficiary free of charge. 7. Rest cures, general health cures and treatment in social welfare institutions. 8. Any illness or injury resulting directly from the beneficiary, s profession. 9. Medically recognized venereal or sexually transmitted diseases. 10. Costs of treatment following diagnosis of HIV or any disease related to HIV, including AIDS and its derivatives, alternatives, or other forms. 11. All costs related to tooth implants, dentures, fixed or movable bridges or orthodontic treatment, unless resulting from violent external means. 12. Vision or hearing correction tests and visual or hearing aids, unless requested by a licensed physician. 13. The beneficiary, s transportation expenses within and between cities in the Kingdom by means other than ambulances of the Saudi Red Crescent or licensed ambulances. 14. Hair loss, baldness or artificial hair. 15. Psychological, mental or nervous disorders, unless of an acute nature as specified in the policy schedule. 16. Allergy tests of any nature, unless relating to medicines, diagnosis or treatment. 17. Equipment, means, drugs and procedures, or hormone treatment aimed at regulating reproduction, contraception, fertility, infertility, impotence, secondary sterility, in-vitro fertilization or any other method of artificial fertilization. 18. Any congenital weakness or deformity unless it is life threatening, except for cases requiring treatment in accordance with a medical report issued by the health facility approved by the Council. 19. Any costs or additional expenses incurred by the beneficiary, s companion during a hospital stay, except for the hospital room and board charges for one companion such as a mother companying her child aged up to twelve years or whenever medically necessary as assessed by the attending physician. 20. Treatment of acne or any treatment relating to obesity or weight problems. 21. Organ or marrow transplant, or implant of artificial organs to replace any organ of the body. 22. Any activities known to involve high risk of exposing a person to an illness or an accident, or is expected to aggravate a previous illness or injury. 23. Alternative medicine procedures and medications. 24. Artificial and ancillary limbs except those required by the beneficiary as per a medical decision issued by the health care facility approved by the Council. 25. Natural changes related to menopause, including menstrual disorders. This policy shall not cover medical benefits or corpse repatriation to home country in claims resulting directly from: 1. War, invasion, acts of foreign enemy, acts of aggression (whether or not war is declared) or civil war. 2. Ionizing radiations, pollution from radioactive activity of any nuclear fuel or waist resulting from the combustion of nuclear fuel. 3. Radioactive, toxic, explosive or other hazardous properties of any nuclear plant or any of its nuclear components. 4. Beneficiary, s service or participation in armed forces or police activities. 5. Riots, strike, terrorism or the like Note: All exclusions listed above are as per CCHI

12 easy steps 5to benefits from the Health Services 3 Always carry your membership card along with your National ID while visiting the Provider. It is preferable to reach the Provider Reception 15 minutes before your appointment 1 Familiarize yourself with the enclosed Providers list and choose the one you would like to visit. If you cannot decide, Saudi Enaya Customer Service would be glad to assist you in selecting an appropriate Provider. 4 If services require prior approval from Saudi Enaya, do not worry. The provider will send us the request and get approvals instantly. Simultaneously, you will receive text messages on the status of your authorization. 2 Call the Provider to book an appointment with your doctor in order to avoid delay at Provider. 5 If you face any difficulties receiving services from the Provider, please contact our customer service for assistance.

13 Feedback or Complaints Saudi Enaya is committed to provide the most enhanced and value adding services to its most esteemed members. Your feedback or even your complaints will give us the opportunity to further improve our services and we can assure you that we will spare no efforts in providing the best solution and services to meet the high standard of your expectations. If you have faced any difficulties related directly or indirectly to Saudi Enaya s services or would like to provide your valuable feedback, please do not hesitate to contact us inside KSA: or outside KSA: or us at: care@saudienaya.com

14 DEFINITIONS Insured/Member: The person (employee or dependent) included under the scheme Card Number: A unique number provided to each Saudi Enaya insured member as an identification. Insurer: Your health insurance company Saudi Enaya Cooperative Insurance Co. Policyholder: The employer or person in whose name the policy is issued. CCHI (Council for Cooperative Health Insurance): Regulator for Health Insurance in Saudi Arabia. Provider: Physician, hospital, group practice, nursing home, pharmacy or any facility, individual or group of individuals that provides a health care service. Reasonable and Customary: It means that the medical expenses are comparable with the level of fees charged by the majority of licensed doctors or hospitals in the member s network in Saudi Arabia. It also means that the medical treatment does not differ significantly from what the licensed doctors consider acceptable for being the usual and customary treatment for any particular service. Benefits: The costs of providing health services included in the insurance cover within the limits shown in the Table of Benefits. Applicable Healthcare Benefits: The mandatory benefits as specified in the regulations set forth by CCHI provide comprehensive coverage. However, depending on your Saudi Enaya coverage you may receive higher benefits, Please refer to your Table of Benefits. Table of Benefits: The attached table of benefit applicable to your plan showing the maximum benefits we will pay for each member. Coverage: The amount and extent of risk covered by Saudi Enaya. Standard Exclusions: The health benefits and services excluded from your coverage.

15 Reimbursement: A method for compensation of expenses incurred by the insured member at a provider. Direct Billing: The facility of non-payment granted to the insured at the provider appointed by Saudi Enaya whereby all such costs are directly billed to Saudi Enaya by the provider. Network: All the primary physicians, specialists, hospitals and other providers who participate in this plan to provide your medical care. A list of your network providers is enclosed with this membership package. Chronic Condition: A medical condition or episode of ill health which persists for a long period. Pre-existing & Chronic Diseases: All pre-existing and chronic diseases are covered except those listed in the Standard Exclusions. Medical Report: A document filed by the doctor explaining the symptoms, diagnosis and treatment given. Emergency: The medical treatment required for an insured person as a result of an accident, or an illness requiring prompt medical attention. Emergency Treatment: You are covered up to 100% of your annual limit for covered emergency services available outside of your network, subject to the geographical coverage as per your enclosed Table of Benefits Out-patient Treatment: The Out-patient benefit covers all eligible treatments, procedures and services other than those listed in the Standard Exclusions. Co-Insurance: Your plan may include a Co-Insurance payment which is the amount that is required to be paid to the provider when you are being treated for an applicable out-patient service. This will be specified on your membership card as a percentage % of the treatment cost with a maximum limit of SAR100. In-patient Treatment: The In-patient benefit covers all eligible treatments, procedures and services other than those listed in the Standard Exclusions.

16 Room Type: Depending on your level of coverage, your hospital room will be specified on your membership card as a normal suite, private room, semi-private room or shared room. Companion Cover: If you have a dependent child that is under the age of 12 or if medically necessary as assessed by attending Physician, Saudi Enaya will pay for a companion to accompany the child during the hospital stay. Dental: Dental benefits cover the cost of consultation, x-rays, normal and surgical extractions, root canal treatment, amalgam/composite filling, gum treatment and prescribed medicines. Optical: The optical benefit includes consultation, vision tests and prescription glasses, including frames. Maternity: Maternity benefits are automatically provided for all eligible females and will cover the cost of pregnancy, normal delivery, caesarean section and maternity complications including legal abortion and miscarriage. (Please refer to the enclosed Table of Benefits) The cost of ear piercing for new born girls and circumcision for newborn boys is also covered under this benefit. Maternity coverage is specified on your membership card with a sign indicating your coverage. Y means Maternity is covered and N means Maternity is not covered.