KHAT AL HAYA (LifeLine TPA)

Transcription

1 KHAT AL HAYA (LifeLine TPA) About us: Our state-of-the-art Group Medical Management system sanction insurance companies to lessen the operational expenses and allow the Insurance companies to focus on their core business strategies. We Offer tailored services that help the Insurance Companies / clients meet their exceptional challenges strategically, operationally, and tactically. We provide best medical services all across UAE professionally, economically & with overall expertise. We are Here: Our Companies Khat Al Hayat is one of the leading medical assistance companies, operating across UAE currently. We are hiring the leading professionals from different countries, smoothing its entry into the international insurance market. Our AIM to become the Number 1 TPA Company in UAE and operating worldwide in claims handling and TPA services. Major international companies entrust us with the providing of medical care services to their members. Having in mind a clear understanding of the claims handling system functioning, we develop a matchless program enabling to speedily process invoices from medical facilities to insurance companies, and to arrange rapid payments to the health providers (Clinics, Pharmacies & Hospitals), obtaining therefore the biggest discount possible on the medical services. Having gained a vast experience in the area of medical administration services, our Cost Control Team achieves an extremely competent and specialized cost containment.

2 Why U Outsource: In order to achieve maximum efficiency in your insurance entity s operations, a TPA can deliver the mandatory resources on-demand while delivering economies of scale. Rather than hiring full-time staff and buying into the latest IT solutions, choose a TPA to take advantage of administrative expansion and external expertise without acquiring expensive and long-term commitments. A TPA is a perfect solution if want to achieve Best in Class and focus on growth and core areas of your company What we Offer: Full Medical Claims Management Services Claims handling/processing Case management Cost containment Fraud investigation Second medical opinion 24/7/365 multilingual call-center Medical escorts services Emergency medical assistance Evacuations/repatriations

3 Our Facilities: WE can administer many different lines of insurance business, including Whole Life Insurance Universal Life Insurance Term Life Insurance Final Expense Insurance Long Term Care Insurance Annuities Supplemental Health Insurance Health Insurance Cancer Insurance Critical Illness Insurance What is KHAT AL HAYA LifeLine TPA? We are neither the insurer (provider) nor the insured (employees or plan participants), but handle the administration of the plan including processing, settlement, and conciliation of claims, record-keeping, and maintenance of the plan, The risk of loss incurred remains with the insurance company, The insurance company commonly contracts a reinsurance company to share its risk. An insurance company hires us to manage its claims processing, provider network and consumption review. While some TPA operates as units of insurance companies, most are often independent like us.

4 Here we Act: Nowadays many insurance and self-insured companies are looking for greater monetary control over medical charges, hoping to reduce their overheads, willing to get rid of fake bills, magnified bills and to foresee costs. We develop state-of-the-art TPA approaches to achieve claims proficiencies and reduce the cost of claim administration for healthcare insurance and selfinsured companies. We have a unified TPA services program for handling claims with know-how in processing and cost control completely. We can offer superior quality managed care as a result of being staffed almost entirely by doctors and nurses. The medical knowledge and proficiency of our staff enables us to control costs by wisely managing each individual case and checking needless expenses. We check the treatment you are receiving is appropriate, medically compulsory, and ensure that all treatments, medical evacuations or repatriations are administered efficiently and always-on time. Our Benefits Include: Quicker, more focused claims management Lower expenditures and reduced cost Instantaneous access to highly trained specialist claims administrators Enhanced control over claims outcomes Safeguarding of customer satisfaction and protection of brand reputation.

5 What makes us Different? Experience and expertise We re there when YOU need us. We offer a matchless and powerful combination of experience, knowledge and ability to reduce costs We offer qualitative service and mutually beneficial outcomes. We offer more than just good management We have focused and flexible team who share a vision and work towards it. We offer a way to manage costs and quality benefits package even with mounting care expenses and the impacts of the Affordable Care Act. We make it possible with end-to-end insurance and employee benefit solutions that work for your business. Our Technical support takes care of : New Client Implementation & Services Insurance Policy Enrollment and Eligibility Insurance Policy Issue in-coordination with insurer & Re-Insurer Insurance Policy Underwriting (application, evaluation) in-coordination with insurer / Reinsurer Insurance Policy Premium Billing in-coordination with insurer

6 Insurance Policy Premium Collection on behalf of insurer Insurance Claims Administration Insurance Claims Processing Compliance & Regulatory Support in-coordination with insurer Insurance & Financial Accounting in-coordination with insurer Insurance Rate Management Client Support & Customer Service Reinsurance Accounting & Reporting in-coordination with insurer & Re-insurer Self-Funded Plans: If you have a stake in employee benefits, you know that workforce wellness and benefits plans are changing at a rate faster than most can follow. Switching to a self-funded plan from Lifetime Benefit Solutions can help. You ll pay only for what you need and use. Plus, with zero premium taxes and lower administration costs, it can add up to some really impressive savings. Our benefits programs are built around you. With a self-funded approach, you choose the benefits and extras. You ll have control without the restrictions, because your plan doesn t need to adhere to many of the state mandates. This gives you the flexibility to create a plan that s perfect for your company. Rather than paying a monthly premium to a commercial insurer, you re responsible for paying for your employees health care claims directly. In other words, you pay the covered claims. You also pay an administrative fee to a Third Party Administrator (TPA) to handle the paperwork, while you pocket the savings.

7 What we do For You: Enrollment and Clients Database Maintenance 24/7 access to Lifeline medical network of more than 500 contracted direct providers all over the UAE (In process). Health Claims Processing Claims payment/management Managing plans with deductibles, co-insurances & selective Providers Network. Strict cost control (cost containment performance) Guaranteed discounts applying Different types of Network Management Reimbursement services settlement Outsourced claims management Workers' compensation claims management Day-to-day operation of the health plan Give you easy access to plan information and reporting Allow you to access the required specialist / super specialist Guide you to go for admission or to consult the specialist to have exact treatment required. Might suggest you to get the treatment done at your home countries that relatives can take care of you and we can reimburse the bills as per the policy norms and condition. Might take an appointment for you and send you to the specialist for chronic / Pre-existing treatment. May arrange the admission booking for you, before you reach the hospital (Pvt only). Handle claims and benefit processing Prepare employer claim utilization reports (as & when required). Delivering the Medical ID cards as and when requested by Insurer (as per the terms)

8 Our Health Care Network Services Includes: Highly qualified multilingual doctors and paramedical personnel with 24/7 / 365 availability, Medical network covering all UAE territories and comprising all types of medical and assistance providers: hospitals, laboratories medical centers, pharmacies, specialists, physiotherapists, dentists and healthcare practitioners. You find clinic/s in every nook and corner to have an easy access. The health providers can be added / deleted based on the request of insurer / re-insurer. Direct billing and cost containment expertise Network out of UAE, in Home countries can be arranged based on policy issued by insurer. Government hospitals will be dealt on reimbursement basis as per the policy terms released by Insurer. Maintaining Database and Issuing Medical ID cards: Once the policy has been issued by insurer, all the records from insurer are passed on to us and all further communication of the Policyholders is with Lifeline TPA regarding Network facilities and claims management system. It is our responsibility to maintain databases of policyholders and issue them identity cards with unique identification numbers. On the basis of details provided by Insurer, Life line TPA will issue a Life Line ID (Physical or Electronic) to each one of the beneficiaries covered under the policy. This card is issued only for identification purpose and should not be construed as an authorization to the hospitals to proceed with the treatment.

9 Life Line TPA ID card may or may not have the photograph (as per the request of insurer). It can be issued in the form of e-card (soft copy of ID card). In case e-card is issued, physical ID card may not be issued. Replacement ID Card(s): Issuance of replacement cards lost by the member will be subject to a replacement charge per card. Once cancelled, cards lost will not be valid for cover and should be returned to Life Line TPA if found (at below address). When a member leaves the scheme or is no longer eligible for membership, the member s card(s) must be returned to the Human Resources and Administration Department before the last day of employment or eligibility & it must be forwarded to LIFE LINE TPA immediately. It is essential that you know your TPA contact details since it is the TPA that the Policyholders are supposed to contact in the case of hospitalization or claim settlement. Call Centre: Operating a Call Centre is one of the many Customer Service operations at lifeline. The bane of almost any Call Center is the number of calls which are in queue, causing irritation to the caller who is forced to listen to some music while waiting to speak to a Customer Service Officer. The Interactive Voice Response System (IVRS) is a fully interactive system which allows callers to check their claims' status without having to wait to speak to a call agent. We, at lifeline TPA have introduced the IVRS system in order to be able to provide our customers - your employees - with a quick and easy-to-use facility which allows them to get status updates instead of having to wait in queue to be able to speak to a Customer Service Officer. This facility, in addition to the web login and the SMS alerts, should be able to provide every customer with an instant alert on any change in status of their claims. Options are available for callers to check their claim status based on their Lifeline ID Card Number, It is therefore very important for the employees to have their ID numbers at hand when calling.

10 Pre-Authorization of claims: This is a process whereby the Customer Service Supervisor Claims (CSSC) will review information to make sure that the insured s medical needs are being met and the most cost effective solution is being utilized. This is done in conjunction with the insured, his attending physician, and the medical facility. For services obtained within the designated provider network in UAE, preauthorization should be sent to Lifeline TPA by the designated provider and not by the member. Pre-authorization is required for the following: In-hospital Admission Extension of Hospital stay Medical / Surgical treatment exceeding the sublimit mentioned in policy. Daycare Services MRI - CT scan -Doppler - Holter monitor etc. Physiotherapy Drugs for over two month stock All dental, maternity and optical treatment etc. Non-emergency out-patient service exceeding the limit Pre-authorization for nonemergency treatment: If non-emergency treatment is obtained from a provider outside the network in UAE OR outside the Area of Cover, the member MUST obtain pre-authorization from lifeline TPA. Value Added Services: We can ask an independent medical practitioner to advise us about the medical facts relating to a claim or to examine the member concerned in connection with the claim (Second Medical Opinion). This is needed very rarely and we use this only where there is uncertainty as to the nature or extent of the medical condition and/or our liability under the policy.

11 Managing All Aspects of Plan Administration to Maximize Efficiency and Savings: Medical Case Management Our case management program looks at the big picture to provide preventative cost control programs, limiting employer exposure in the future and helping to control rising medical expenses today. Early identification of potential health risks provides the opportunity to reduce medical treatment costs and improve member outcomes. Sophisticated Claims Processing System Our claims processing software is a webbased solution developed for the health care payer industry. This system has the flexibility to allow for the programming of client-specific benefits. Lifetime Benefit Solutions prides itself on: Access to the largest health provider network Access to national health provider network solutions to meet the specific needs of our clients. Prescription Benefit Management via partnerships with several of the nation s leading Pharmacy Benefit Managers (PBMs) Tailor-made product(s) designed to meet your specific needs Unmatched flexibility regarding plan design Personalized quality service Procedure for Treatment or settlement of claims outside the Designated Provider Network / Outside the Area of Cover (Reimbursement basis): The member MUST obtain pre-authorization from Life Line TPA. The member must pay 100% of all charges to the medical provider at the time of treatment.

12 To obtain reimbursement the member must submit the following original documents (Photocopies are not Acceptable) A. Medical Expenses Claim Form, completed and signed by the member and the treating physician. b. A separate Doctor s Report should be provided if a Medical Expenses reimbursement Claim Form is not completed by the treating physician as in «a» above or if the space provided in the Claim Form is insufficient to complete details of the treatment. c. A separate medical report is required for all cases of in-patient and/ or daycare treatment. d. In addition to the Medical Expenses Claim Form Original prescription and pharmacy bills are required. These must detail the name and cost of each prescribed drug or medication. e. Original diagnostic investigations (if any) comprising of laboratory investigation(s), X-ray etc., reports and invoices must be submitted. f. Original receipt of payment must be provided. g. Payment of reimbursement claims will be made within 30* working days following receipt of complete documents by Life Line TPA. Our Standard Word Commitment Chart: CLAIMS CENTER Helpline for Providers and Insured Members Calls answered within 20 seconds 90% SERVICE LEVEL Available 24 hours a day, 7 days a week

13 On Customer request call backs within 10 minutes of requested time Issue response to written correspondence, where appropriate Claim utilization notification level 95% Within 2 working days within 3 working days from the date of request CLAIMS PROCESSING Complaints/ queries from customers or Medical Providers Claims assessed correctly in line with overall benefits, terms, exclusions, conditions, and endorsements. Claims correctly identified, reported and processed as per TOB ( table of benefits ) Network claims Backlog Reimbursement claims turn-around time SERVICE LEVEL Acknowledged within 48 hours, and full response within 5 working days 99% 95% Not to exceed 40 days 95% processed within 15 working days Concern about some aspect of our service, if at all occasionally arises. In such circumstances, Life Line s Managers have wide authority to settle problems and will do all they can help. Address: KHAT AL HYAT (LifeLine TPA) Office # 303, Fatima Abdullah-Bin-Owais Bldg., Kalba Rd., National Paint, P.O. Box: 79363, Sharjah, UAE PH: FAX: Please write us: [email protected]