Arabic (العربية الموحدة)English (United Kingdom)
Home Company Profile How does it work

How does it work?

 

Mechanism of offering insurance:


What the subscriber should do when gets ill ?

Every subscriber (employee or dependent) gets a medical insurance card that contains personal information with picture. and get his / her special insurance number. Through this card s/he can have all needed medical services ". Every subscriber can receive the medical treatment in most of main hospitals in Sana'a such as (Technology Science university hospital/ Saudi German Hospital/ Modern German hospital/ Al-Ahli Typical Hospital / Haddah Hospital/ Azal Hospital/ Magraby hospitals and centers/ Almadina hospital/ Ibn- Sena’a hospital and others. In addition, He / she can also review tens of physicians, pharmacies, and diagnostic centers (distributed all over the capital Sana'a) as well as the main hospitals in the other governorates like Aden, Taiz, Hadramot, Hajja, Hudida, Ibb, Dhamar, Mareb, …….ect.

The employee's or dependent's has the freedom to choose the health providers and MIS will observe the patient and will pay the expenses directly to health providers wherever S/he goes.

The employee can go to any consultant doctor, If the patient dose not know a suitable doctor, he can call or come to  MIS. When there is an emergency case subscriber can go to the nearest hospital (within or outside the network) or calling the company. The subscriber does not have to go back to the company or your company, as there is a service commissary who receive the co-payment which depends on the service class according to your company benefits.

Every subscriber has an electronic permanent central file within the TPA system.the medical insurance files for each covered employee and each covered dependent including all his/ her medical expenses with balances of amounts remaining in the annual per person reimbursement ceiling.

The service provider offers the appropriate service within the agreed mechanism, and a complete attention given to the card holder, some hospitals has also assigned special employees to receive MIS card holder within the medical network

When admission, or the more expensive procedures such as MRI or endoscopy are needed ,the hospitals contact the MIS agreements center, and agreements are given within few minutes. (the duration can be determined in the contract).

MIS (medical procedures editing department) takes care of reviewing all the medical procedures from the point of view of whether or not the procedure is needed. The bills are also reviewed when received as the costs and the physician fees, and prevent the exaggeration of using the medical equipment and providing the service providers with the appropriate notes and comments.  There is a medical staff that makes field visits to make sure of the quality of the offered medical services.


Central point of contact :

Central point of contact is available for the medical services providers to answer all their questions and provide them with the required agreement, and answer all the questions of the subscribers through MIS offers information center : continues 3 hot lines around the clock for queries of the subscribers. (Continuity of Services).

 

Reimbursement
In case when the subscriber receive the medical service outside our medical network, there is a prompt reimbursement system, Actually we attempt to decrease its cost as much as possible for it acts sometimes as an entry for an abuse and  this decrease happens through several ways:

1. Usually we put the cash reimbursement payment with higher co-payment than the direct service providers coverage. (It differs from contract to other)

2. We can Include any health providers recommended by the contracted institutions (or subscribers) within the medical network as much as possible.

3. Allowing the complete reimbursement for the physicians investigations and then prescribing the medicine or making the investigations using the ID cards in the pharmacies and the contracted diagnostic centers.

 


In case there is a deserved reimbursement such as in emergencies or in case of being in a city with no medical service provider, or any visit to any consultant doctor outside the network. The reimbursements are done with the use of the reimbursement form, These forms specify a list of documents required to be appended to each claim and otherwise provide instructions for claim filing. Within maximum one weak the preparation and the revisions of the subscriber reimbursement check and deliver it to him / her according to the mechanism in the agreement with the contracted institutions..

 

The reports extraction options :-

MIS can provide any reports according to the need: Claims for all subscriber including the name of the subscriber, medical expenses with its type., Claims from date to date, According to the claims status (under processing, ready ,closed), According to the subscribers type or all or some of them, The network and none network claims or both, Claims for all types of providers or one of them, Claims for one procedure or a group of procedures. Subscribers claims that exceed a certain limit. The reports can include all outstanding claims and a brief description of why claim has not been paid. And any cases uncovered by the plan or amounts exceeding allowable ceilings