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Provider Manual - Dubai & Northern Emirates

Provider Relations Department

Provider Manual - Dubai & Northern Emirates

Manual Outlines
1.

Introduction ................................................................................................................ 3

2.

Membership Card Instructions ....................................................................................... 4

3.

New Enhanced Plan Names and Network Names .............................................................. 9

4.

Patient Consent ..........................................................................................................11

5.

Non-Discrimination .....................................................................................................12

6.

Receiving Members .....................................................................................................13

7.

Daman Forms ............................................................................................................14

8.

Daman On-Line Eligibility Check ...................................................................................50

9.

thiqa On-Line Validity ..................................................................................................51

10.

Authorisations ............................................................................................................52

11.

Medications Dispensing ...............................................................................................56

12.

E-Claims....................................................................................................................59

13.

Paper Claims ..............................................................................................................61

14.

Reconciliation .............................................................................................................65

15.

Audit .........................................................................................................................65

16.

Obligation for Addition/Deletion of Branches ..................................................................67

17.

Daman Contact List ....................................................................................................68

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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1.

Introduction
The Provider Manual is a document designed to outline the administrative procedures,
requirements and specific instructions that need to be completed by Network Providers when
rendering Healthcare Services to Beneficiaries.
This Provider Manual shall be read in conjunction with the Standard Provider Contract signed
between National Health Insurance Company Daman (PJSC) (hereinafter referred to as
Daman) and Provider. If not specifically defined herein, all definitions used in the Provider
Manual are the same as in the Standard Provider Contract.
This Provider Manual is furnished to all Network Providers that are located in Dubai and
Northern Emirates only
Daman may modify the Provider Manual by sending a written notification to Network
Providers thirty (30) calendar days prior to such modification.

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2.

Membership Card Instructions


The Membership Card is an identification card issued by Daman to the Beneficiary. It
contains coverage instructions which need to be checked by the Network Provider prior to
rendering Healthcare Services to Beneficiaries.
A.

Membership Card Instructions I:


Old Card Layout:

New Card Layout:

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New Enhanced Card Layout:

B.

Membership Card Instructions II:


Old Card Layout:

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New Card Layout:

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C.

thiqa Top Up Membership Card Instructions III:


Un-Combined Card Layout:

Unified Card Layout:

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New Unified Card Layout:

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3.

New Enhanced Plan Names and Network Names


New plan names and network names will be implemented for all new and renewed business
after July 15th, 2013. All Enhanced Plans will be renamed except Premier.
New Plan Names for Group Plans
Existing Network
New Network
Names within
Names within UAE
UAE

Existing Name

New Plan Names

thiqa

thiqa C1

Exclusive 1

NW1
NW UAE/ AD Public
& Private

Premier

Premier

Exclusive 1

NW1

Premier Plus

Premier Plus

Exclusive 1

NW1

Premier Ext

Premier Ex

Exclusive 1

NW1

Premier TC1

Premier TC1

Exclusive 1

NW1

Premier TC2

Premier TC2

Exclusive 1

NW1

Premier TC3

Premier TC3

Exclusive 1

NW1

Premier TC4

Premier TC4

Exclusive 1

NW1

Global

Enhanced Platinum

Exclusive 1

NW1

Global Plus Ext

Enhanced Platinum Plus Ex

Exclusive 1

NW1

Global Plus

Enhanced Platinum Plus

Exclusive 1

NW1

Global Plus TC1

Enhanced Platinum Plus TC 1

Exclusive 1

NW1

Global Plus TC2

Enhanced Platinum Plus TC 2

Exclusive 1

NW1

Global Plus TC3

Enhanced Platinum Plus TC 3

Exclusive 1

NW1

Global Plus TC4

Enhanced Platinum Plus TC 4

Exclusive 1

NW1

International

Enhanced Gold

Exclusive 1

NW1

International Ext

Enhanced Gold Ex

Exclusive 1

NW1

International Plus Ext

Enhanced Gold Plus Ex

Exclusive 1

NW1

International Plus

Enhanced Gold Plus

Exclusive 1

NW1

International Plus TC1

Enhanced Gold Plus TC 1

Exclusive 1

NW1

International Plus TC2

Enhanced Gold Plus TC 2

Exclusive 1

NW1

International Plus TC3

Enhanced Gold Plus TC 3

Exclusive 1

NW1

International Plus TC4

Enhanced Gold Plus TC 4

Exclusive 1

NW1

Regional

Enhanced Silver

Comprehensive 2

NW1

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Regional Ext

Enhanced Silver Ex

Comprehensive 2

NW1

Regional Plus

Enhanced Silver Plus

Comprehensive 2

NW1

Regional Plus TC1

Enhanced Silver Plus TC 1

Comprehensive 2

NW1

Regional Plus TC2

Enhanced Silver Plus TC 2

Comprehensive 2

NW1

Regional Plus TC3

Enhanced Silver Plus TC 3

Comprehensive 2

NW1

Regional Plus TC4

Enhanced Silver Plus TC 4

Comprehensive 2

NW1

UAE

Enhanced Bronze

Comprehensive 3

NW2

UAE Ext

Enhanced Bronze Ex

Comprehensive 3

NW2

UAE TC1

Enhanced Bronze TC 1

Comprehensive 3

NW2

UAE TC2

Enhanced Bronze TC 2

Comprehensive 3

NW2

UAE TC3

Enhanced Bronze TC 3

Comprehensive 3

NW2

UAE TC4

Enhanced Bronze TC 4

Comprehensive 3

NW2

UAE Limited

Core Silver

Essential 5

NW5

UAE Optima

Core Silver R

Essential 5

NW5

Basic Plus

Core Bronze

Essential 5

NW5

TC Plus 2

TC Plus 2

TC Plus 2

NW1

TC Plus 3

TC Plus 3

TC Plus 3

NW1

TC Plus 4

TC Plus 4

TC Plus 4

NW1

Core Chrome IP

Core Chrome IP

Essential 5
Hospitals only

NW5

Core Bronze IP

Core Bronze IP

Value 3 Hospitals
only

NW2

New Plan Names for Individual/ Small Groups Plans


Existing Name

New Plan Names

Premier SG

Premier SG

Global SG
International SG
Regional SG
UAE SG

CarePlatinum
Enhanced Platinum SG
CareGold
Enhanced Gold SG
CareSilver
Enhanced Silver SG
Care Bronze
Enhanced Bronze SG
Core Silver R SG

UAE Optima SG

Existing Network
New Network
Names within
Names within UAE
UAE
Exclusive 1

NW1

Exclusive 1

NW1

Exclusive 1

NW1

Comprehensive 2

NW1

Comprehensive 3

NW2

Essential 5

NW5

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4.

Patient Consent
Prior to submitting any Claims related to Healthcare Services rendered to Beneficiaries, the
Provider shall ensure that the below Medical Consent Form (the Medical Consent Form) is
signed by the Beneficiary and enclosed in his medical file. The Medical Consent Form must be
filed/made available in the patients Medical Record at all times.
Medical Consent Form allows Daman to access Beneficiaries Medical Records at the Network
Providers facility and in the event Daman discovers that a medical file does not contain a
signed copy of the Consent Form, Daman will be entitled to recover from the Provider all
payments related to this file.

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5.

Non-Discrimination
The Provider shall not discriminate in any way against any of Damans members with respect
to the provisions of the healthcare services on account of race, religion, creed, color, national
origin, sex, age, marital status, physical handicap, political beliefs or affiliation, or
membership in any lawful organization.
The Provider should provide the healthcare services to Damans members without regard to
coverage status in the same professional manner and with the same degree of care, skill and
diligence as the Providers provide to other patients, and in accordance with generally
accepted scientific and technical principles and standards of ethics.

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6.

Receiving Members
Whenever a Healthcare Service is sought by a Beneficiary, the Network Provider should
adhere to the following steps/procedures:
a)

Check Membership Card

b)

Revise relevant Schedule of Benefits (SOB)

c)

Follow Damans Authori


uthorisationprotocol

d)

Render the covered Healthcare Service

e)

Submit the Claim to Daman

f)

Receive
e the payment from Daman

Receiving Top-up
up Members

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7.

Daman Forms
Below are the Forms in relation to Healthcare Services
Network Providers are required to comply with below listed Daman Forms prior to rendering
any Healthcare Services
For Emergency Services, Provider must render the Healthcare Services and seek
authorisation within 24 hours from providing the Emergency Services.
Daman Forms are segregated as following:
I.

II.

Authorisation Requests Forms:


a.

Authorisation Request for Inpatient / Outpatient Form

b.

Request for Second Opinion Form

c.

Chronic Medication Form

d.

Medical Appliances & Equipment Form

e.

Dental Request Form

f.

thiqa Orthodontic Assessment Form

g.

thiqa Request for Orthodontic Second Opinion

h.

PET Scan Pre-Authorisation Form

i.

Physiotherapy & Occupational Therapy Form

Approval Forms:
a.

Authorisation Letter for Outpatient Services

b.

Authorisation Letter for Hospitalisation

c.

Authorisation Letter for Dental Services

III. Rejection Forms:


a.

Rejection Letter for Outpatient Services

b.

Rejection Letter for Hospitalisation

c.

Rejection Letter for Dental Services

IV. Accommodation Upgrade Acknowledgement Form (thiqa top up)

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I.

Authorisation Requests Forms:


The treating licensed physician must fill, sign and stamp below Daman Forms prior to
rendering any related Outpatient / Inpatient Healthcare Service excluding Emergency
Services. Network Provider must submit the related Form to Daman seeking a Prior
Authorisation if required.

a.

Authorisation Request for Inpatient / Outpatient Form:


Network Provider must submit the following Form for all covered Inpatient /
Outpatient Healthcare Services

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b.

Request for Second Opinion Form:


This form is applicable for all Healthcare services second opinion excluding
Orthodontic Treatment.
Daman may require additional opinions prior to Authorisation /rejection. The
second opinion doctor will consult the Beneficiary and send back to Daman the
form pertaining to his assessment along with his signature and stamp.
Daman shall then send to the treating physician its Authorisation / Rejection of the
medical treatment. In exceptional cases and where required by Daman, third
opinion may be sought.

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c.

Chronic Medication Form:


Network Providers must submit the following Form for all covered chronic
Pharmaceutical Services that are subject to Prior Authorisation.

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d.

Medical Appliances & Equipment Form:


Network Provider must submit to Daman the following Form for any covered
Medical Appliances / Equipment Services that are subject to Authorisation.

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e.

Dental Request Form:


Network Provider must submit the following Form for all covered Dental
Healthcare Services that are subject to Authorisation.

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f.

thiqa Orthodontic Assessment Form:


For Orthodontic services that are subject to Authorisation for thiqa Beneficiaries,
the treating Dentist must fill, sign and stamp the thiqa Orthodontic
Assessment Form along with the countersignature of the Beneficiary.
Network Provider must then submit the form to Daman requesting for Prior
Authorisation.

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N.B. The Orthodontic Assessment Form is filled according to the following


IOTN Orthodontic Grading System:
Grade 1

is almost perfection.

Grade 2

is for minor irregularities such as:

 Slightly protruding upper front teeth.


 Slightly irregular teeth.
 Minor reversals of the normal relationship of upper and lower teeth which do not interfere
with normal function.
Grade 3

is for greater irregularities which normally do not need treatment for health
reasons:

 Upper front teeth that protrude less than 4 mm more than normal.
 Reversals of the normal relationship of upper teeth which only interfere with normal
function to a minor degree; by less than 2 mm
 Irregularity of teeth which are less than 4 mm out of line
 Open bites of less than 4 mm
 Deep bites with no functional problems.
Grade 4

is for more severe degrees of irregularity and these do require treatment for
health reasons:

 Upper front teeth that protrude more than 6 mm


 Reversals of the normal relationship of upper teeth which interfere with normal function
greater than 2 mm
 Lower front teeth that protrude in front of the upper more than 3.5 mm
 Irregularity of teeth which are more than 4 mm out of line
 Less than the normal number of teeth (missing teeth) where gaps need to be closed
 Open bites of more than 4 mm
 Deep bites with functional problems
 More than the normal number of teeth (supernumerary teeth)
Grade 5

is for severe dental health problems:

 When teeth cannot come into the mouth normally because of obstruction by crowding,
additional teeth or any other cause.
 A large number of missing teeth.
 Upper front teeth that protrude more than 9 mm
 Lower front teeth that protrude in front of the upper more than 3.5 mm and where there
are functional difficulties too
 Cranio-facial anomalies such as cleft lip and palate.

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g.

thiqa Request for Orthodontic Second Opinion:


After receiving the thiqa Orthodontic Assessment Form, Daman will fill the
details of the Beneficiary and send a Request for Orthodontic Second
Opinionto designated providers for Orthodontic Second Opinion.
The Second opinion dentist will consult the Beneficiary and send back to Daman
the form pertaining to his assessment along with his signature and stamp.
Daman shall then send to the treating dentist its Authorisation / Rejection of the
orthodontic treatment.

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h.

PET Scan Pre-Authorisation Form

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i.

Physiotherapy & Occupational Therapy Form

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II.

Approval Forms:
a.

Authorisation Letter for Outpatient Services:


Network Provider must receive the following Form for all Outpatient Healthcare
Services that are subject to Prior Authorisationbeforerendering the service,
excluding Dental / Medications.
Authorisation Letter for Outpatient is considered valid for 30 calendar days
starting on the authorisation effective date and ending on the authorisation expiry
date.

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b.

Authorisation Letter for Hospitalisation:


Network Provider must receive the following Form for all Inpatient Healthcare
Services that are subject to Prior Authorisationbefore rendering the service.
Authorisation Letter for Inpatient is considered valid for 30 calendar days starting
on the authorisation effective date and ending on the authorisation expiry date.

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c.

Authorisation Letter for Dental Services:


Network Provider must receive the following Form for all dental Healthcare
Services subject to Authorisation
Authorisation Letter for Dental Service is considered valid for 30 calendar days
starting on the authorisation effective date and ending on the authorisation expiry
date mentioned on the form.

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III. Rejection Forms:


Daman will not be liable for any Healthcare Services that were totally rejected to
Network Provider and pointed at in the following Forms.
1.

Rejection Letter for Outpatient Procedures:

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2.

Rejection Letter for Hospitalisation:

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3.

Rejection Letter for Dental Services:

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IV.

Accommodation UpgradeAcknowledgement Form (thiqa top up)

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8.

Daman On-Line Eligibility Check


The Schedule of Benefits specifies the Healthcare Services covered by Daman according to
the type of plan the Beneficiary is enrolled in. Prior to rendering any Healthcare Service, the
Provider should check the type of plan mentioned on the Membership Card of the Beneficiary
in order to ensure that the services sought by the Beneficiary are Covered Services.


Network Provider shall log on to www.damanhealth.aeand for unregistered providers,


please register with a user name and password to access the tool
Below are the instructions regarding how to perform the search (please note it is important to
follow the instructions as provided by Daman):
1-

Sign in with User Name and Password

2-

Go to Member Validity.

3-

Enter the Beneficiarys information with the following data:


a.

Member Number

b.

Valid Policy Number

c.

Service Date.

4-

Network Provider shall check for Beneficiarys validity first.

5-

The below message will be displayed for Beneficiarys validation: Member is valid/ not
valid.

6-

If the Beneficiary is valid then SOBs & Exclusions list will be displayed.

7-

Network Provider must be able to view the current SOBs and general exclusions related
to the Beneficiary.

8-

In case the Network Provider enters the current date for deleted Beneficiary with an
expired card, the system will give a message Member expired or deleted.

9-

In case the Network Provider attempts to enter a future date then a message will
appear and no SOBs, Exclusions list will be displayed.

10-

The message displayed in the case of future dates is:


Prospective dates are not allowed for Services to be performed subsequent to insert
current date. Please make sure that you repeat this check on the service date.

11-

After display of the SOBs and Exclusions list the following disclaimer should appear:
Further to displayed SOBs/Exclusion List, kindly take into consideration HAAD/Daman
circulars which were effective at the time of the service date.

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9.

thiqa On-Line Validity


In order to check thiqa card validity, please follow below instructions regarding how to
perform the search:
1-

Network Provider shall log on to www.thiqa.ae

2-

Go to Medical Provider

3-

Click on thiqa card validity

4-

Please enter thiqa card Number or Emirates ID Number.

5-

The below message will be displayed for Beneficiarys validation: Member is valid/ not
valid.

6-

If the Beneficiary is valid, please print the Validity receipt to be used forAuthorisation (if
required) and Billing Purposes.

7-

If the Beneficiary is not valid, please call Daman Call Center (800 432626) for further
clarification

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10. Authorisations
For Emergency Services, Provider must render the Healthcare
Authorisation within 24 hours from providing the Emergency Services.

Services

and

seek

Network Providers are required to comply to use Daman Forms before rendering any
Healthcare Service.
All Pre Authorisation Requests should be sent to Authorisation Department by Fax as per the
Number specified on the form except for thiqa Dental Pre-Authorisation Requests which are
sent through E-mail to AuthorisationQueries@damanhealth.ae
Providers that signed Standard Provider Contract E- Claims should send the Pre-authorisation
requests withrhe specified CPT Codes for pre-approval
The following Plans are exempted from Authorisation:


ENHANCED SILVER PLUS (PREVIOUSLY REGIONAL PLUS)


1. Mubadala Company
2. Federal Authority for Nuclear Regulation
3. Emirates Nuclear Energy Corporation (ENEC)

ENHANCED GOLD PLUS (PREVIOUSLY INTERNATIONAL PLUS)


1. Mubadala Company
2. Federal Authority for Nuclear Regulation
3. Emirates Nuclear Energy Corporation (ENEC)

ENHANCED PLATINUM PLUS (PREVIOUSLY GLOBAL PLUS)


1. Mubadala Company

PREMIER PLAN
1. Crown Prince Court
2. Emirates Nuclear Energy Corporation (ENEC)
3. Federal Authority for Nuclear Regulation
4. General Secretariat of Executive Council
5. Ministry Of Presidential Affairs
6. Mubadala Company
7. Technology Development Committee

EXECUTIVE PLAN/PREMIER PLUS

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The following procedures excluding Medications require Pre-Authorisationby the Network Providers:
Pre- Authorisation

Core Silver
(Previously UAE
Limited Plan)

Core Silver R
(Previously UAE
Optima)

Enhanced Bronze
(Previously UAE
Plan)

Enhanced Bronze Ex
(Previously UAE
Extended Plan)

UAE SEHA Standard


Plan

UAE SEHA Plus Plan

Regional SEHA Prime


Plan

Enhanced Silver Ex
(Previously Regional
Extended)

Dental

Core Chrome Ex
(Previously Abu
Dhabi Extended
Plan)

Annual Screening for Breast, Prostate


Cancer , Colorectal Cancer

Medical Checkup

Medical Equipment and Appliances

Podiatry Services

Alternative Medicine

Chiropractic Services

Core Bronze
(Previously Basic
Plus)

Occupational / Speech Therapy

Cardiac Pulmonary Rehabilitation

Rehabilitation

Physiotherapy

Dietician

Chemotherapy / Radiotherapy / ESWL

Psychiatry

Endoscopies

Abu Dhabi Plan

Home Nursing

Diagnostic MRI / CT / PET Scan

Inpatient and Day Care

Visit Visa Plan

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Enhanced Silver Plus


(Previously Regional
Plus)

Enhanced Gold
(Previously
International Plan)

Enhanced Gold Ex
(Previously
International
Extended)

Enhanced Gold Plus


(Previously
International Plus)

Enhanced Platinum
(Previously Global
Plan)

Enhanced Platinum
Plus (Previously
Global Plus)

Premier Plan

Premier Extended

thiqa Plan

(Crown , Inlay /On lay, Veneer, Bridge,


Implant, Orthodontic, Dentures)

(HCT ,
ZU, UAEU)

Enhanced Silver
(previously Regional
Plan)

Enhanced Bronze
TC2 / TC3 / TC4

Enhanced Silver Plus


(Previously Regional
Plus) TC2 / TC3 /
TC4
Enhanced Gold Plus
(Previously
International Plus)
TC2 / TC3 / TC4

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Enhanced Platinum
Plus (Previously
Global Plus) TC2 /
TC3 / TC4

Premier TC2 / TC3 /


TC4

thiqa Top-Up Authorisation Protocol:


A

For services requiring Pre-authorisation on both thiqa& Top Up (TC1 Cards


Only)
Old Card Layout (Un-combined Card):


Members Card which does not mention thiqa member number:

The Network Provider is to fill 1 thiqa Authorisation Request carrying both member
IDs and send it to Daman in a single fax/email

New Card Layout (Combined Card):

Members Card which mentions thiqa member number:

The Network Provider is to fill 1 thiqaAuthorisation Request carrying both member


IDs and send it to Daman in a single fax/email

For services requiring Pre-authorisation onthiqa Card Only




The Network Provider is to fill 1 thiqaAuthorisationRequest carrying thiqa member


ID and send it to Daman in a single fax/email.

For services requiring Pre-authorisationonthiqa Top Up Card Only

The Network Provider is to fill 1 Daman Authorisation Request carrying Top Up


member ID and send it to Daman in a single fax/email.

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11. Medications Dispensing


Network Providers are required to comply with Medications Dispensing guidelines and rules,
as set out in Daman Provider Manual and Standard Provider Contract prior to rendering any
pharmaceuticals Services that are subject to Prior Authorisation.
The Network Provider should submit a PriorAuthorisationrequest to Daman before
dispensing any medication(s) for the following cases:
Medications
Exceeding
90 days

Medications Exceeding
30 days

Plans Exempted
fromAuthorisation
ENHANCED SILVER PLUS
(PREVIOUSLY REGIONAL PLUS)
Mubadala Company
Federal Authority for Nuclear
Regulation
Emirates Nuclear Energy
Corporation (ENEC)
ENHANCED GOLD PLUS
(PREVIOUSLY INTERNATIONAL
PLUS)
Mubadala Company

Core Bronze
(Previously Basic Plus)
Core Chrome Ex
(Previously Abu Dhabi Extended
Plan)
All Other Plans

Federal Authority for Nuclear


Regulation
Emirates Nuclear Energy
Corporation (ENEC)
ENHANCED PLATINUM PLUS
(PREVIOUSLY GLOBAL PLUS)

Core Silver
(UAE Optima)

Mubadala Company
PREMIER PLAN
Crown Prince Court

Core Silver R
(Previously UAE Optima)

Emirates Nuclear Energy


Corporation (ENEC)
Federal Authority for Nuclear
Regulation
General Secretariat of Executive
Council
Ministry Of Presidential Affairs
Mubadala Company
Technology Development
Committee
EXECUTIVE PLAN/PREMIER
PLUS

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Dental Prescription

1.

2.

3.

Psychiatric Medication
1.

UAE SEHA Standard Plan

2.

UAE SEHA Plus Plan

Priorauthorisationnot required for all


plans.

3.

Regional SEHA Prime Plan

4.

Enhanced Bronze TC2 / TC3 / TC4

Dental pharmacy to be covered under OP


pharmaceuticals limit and applicable coinsurance (if any).

5.

Enhanced Silver Plus (Previously


Regional Plus) TC2 / TC3 / TC4

6.

Enhanced Gold Plus (Previously


International Plus) TC2 / TC3 / TC4

7.

Enhanced Platinum Plus


(Previously Global Plus) TC2 / TC3 /

Dental pharmaceutical services on TOP UP


cards do not require authorisation.

TC4

8.


Premier TC2 / TC3 / TC4

For Chronic Medication, Pharmacists should follow the procedures below if


Prior Authorisations required:
1.

Fill the Chronic Medication Form with the appropriate information which
includes the Patients Information, Drug Name, Strength, Dosage, Duration of
Treatment, Total Number of boxes and Total AED Price; and

2.

Send by fax with a copy of the Beneficiary Membership Card and the Chronic
Medication Form to the AuthorisationDepartment on 02-6149777 requesting an
approval;

3.

If authorised by Daman and upon dispensing the chronic medications, the


Pharmacist shall ensure that the Beneficiary signs on the prescription indicating
that the medication was received.

12. Authorisation Dashboard




Provider will need to login using their username and password.

For unregistered providers, please register with a user name and password to access the
tool
To search for Authorisations for Enhanced and Basic members please follow
www.damanhealth.ae

To search for Authorisations for Thiqa members please follow www.thiqa.ae

Below are the instructions regarding how to perform the search (please note it is important
to follow the instructions as provided by Daman):
1. Go to More then Authorisation Dashboard.
2. The Provider will have the following Search options to filter authorisations
 Date From and To is a mandatory field for search in provider search.
 Provider can view authorisations issued within the last 90 days.
 In case the provider has more than 100 authorisations in the past 90 days then
the following disclaimer will be shown to the provider;
Only 100 records can be displayed, in case you
need to check for further
records please use the above filtering options.
 The provider may choose not to filter as well. This will display all authorisations
records.

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3. Providers will be able to :


 Track the status of the prior authorisation requests.
 Print authorisations for approved and rejected requests.
 See all records that are currently under process.
4. In case the provider search's for a Daman member in the Thiqa website the following
disclaimer is displayed for the provider
Please use Daman Website to search for Member Authorisation
The same will apply for the Thiqa members in Daman website.

5. In case no authorisation exists for the member then the following disclaimer will be
displayed for the provider
No records to display

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13. E-Claims
All Network Providers shall submit their Claims electronically to Daman via the following link:
www.eclaimlink.ae
A.

Submission:
1-

All Providers must submit their Claims no later than thirty (30) calendar days from
the end of the month of Healthcare Services provided to the Beneficiary.

2-

Receiving requirements:
a.

The file shall be submitted in XML File format at: www.eclaimlink.ae

b.

File shall be named as following


Example: INS026-H100-MAR2013-OP-ENH-SUB
TPA023-H100
H100-MAR2013-OP-TQA-SUB

c.

If a provider is having more than one bat


batch
ch (and would like to split
submissions),add 01,02 as suffix
Example::

d.

B.

C.

INS026
INS026-H100-MAR2013-OP-ENH-SUB-01
01

The Network Provider shall adjust all electronic transactions related to PriorPrior
Authorisation
uthorisationRequests / Claims Submission with the Payer ID listed in below
matrix based on the submitted product.

Resubmission:


Within Forty Five (45) calendar days from the date of receipt of remittance advice.

Up to a maximum of three (3) times

Delayed Resubmission will lead to complete rejection of payment

Resubmission types:
The Provider shall segregate the resubmission of XML files by Plan by Resubmission
type.
The following are Resubmission types:


Correction Type:
o

This type is applicable in case the Provider conducts any changes within the
claim
itself
(for
example
Service
Code/CPT
Code/CPT-4
Code/Price/A
Code/Price/AuthorisationNumber/Diagnosis
Number/Diagnosis Code/etc.).

This type shall be treated as a new claim. Therefore the Provider should
resubmit and include all activities with amounts (pai
(paid/unpaid).
d/unpaid).

The Provider shall add resubmission comments indicating what was


corrected from the original submission.
INS026-H100-MAR2013-OP-ENH-RESUB-CORRCTION
CORRCTION
Example:: INS026

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Internal Complaint Type:


o

This resubmission type is applicable for rejected medical services and


contested by the Provider.

The Provider shall resubmit the contested services and contested amounts
only along with the related unpaid amount (not to be treated as a fresh
claim).

The Provider shall add his comments by specifying the rejected service along
with his justification for rendering the Service (Providers can attach PDF
documents e.g. Medical Report/ Discharge Summary/etc.).
Example: TPA023-H100-MAR2013-OP-TQA-RESUB-INTERNAL COMPLAINT
N.B.: Correction and internal complaint must be resubmitted with Daman
claim ID made available to providers along with the Remittance Advice sent
back with respect to the initial submissions.

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14. Paper Claims


Claims should be submitted within Thirty (30) calendar days maximum from the end of the
month of Health Services provided to the Beneficiary in separate batches with separate
statement of account for each batch.

thiqa 2 batches: ( inpatient/ outpatient )

Enhanced 2 batches: ( inpatient/ outpatient)

Out-Patient Claims requirements:


Out-patient Claims should include the following:

One itemised Invoice with all services provided per visit or different invoices for
different services.

Original Out-patient Claim Form with Beneficiarys signature.

Copy of Cash Receipt. (Co-insurance / Co-pay / deductibles collected from Beneficiary)

Copy of the Daman Card.

Copy of any Laboratory or X-ray results.

Copy of Referral Letter (if patient is referred from other provider).

Original Authorisationfor Out-patient procedures if any.

Provider code must appear on all Claims and Invoices.

In-Patient Claims requirements:


In-patient Claims should include the following:

One itemised Invoicewith all services provided during Admission or different Invoices for
different services.

Original AuthorisationRequest for Hospitalisation.

Copy of the Daman Card.

Original AuthorisationLetter for Hospitalisation.

Copy of any Laboratory or X-ray results.

Copy of Referral Letter (if patient is referred from other provider).

Discharge Summary.

Provider code must appear on all Claims and Invoices.


Note:
o

All submitted Claims must have the Beneficiarys signature & the Physicians
signature and stamp.

Original Authorisations for Out-patient procedures / Hospitalisation received by the


provider will have to be stamped (identifying the received fax as original).

Pharmacy Billing Procedure:


Pharmacy Bills should include the following:

One itemised Invoicewith all medication provided for the Beneficiary.

Original Prescription signed by the patient.

Copy of the Out-patient Claim Form with patients signature.

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Copy of the Damans card.

Copy of cash receipt.(Co-insurance / Co-pay / deductibles collected from Beneficiary)

Original AuthorisationLetter (if any).

Provider code must appear on all Claims and Invoices.


Note:
o

Original Prescription can only be replaced by a copy in case a controlled or semi


controlled medication is dispensed or in case some of the prescribed medication(s)
are unavailable at the pharmacy.

In-house Pharmacies related to Hospitals / Medical Centers:

The provider should include the In-house Pharmacy billing related to Hospital /
Medical Center along with the Out-patient / In-patient invoice to make it as a
single Encounter under one Claim.

Monthly Statement of Account:


A statement of account should be submitted by the Provider with every submission of Claims
and it should be prepared per batch with following information:

Serial Number

Medical Record Number

Beneficiarys Card ID Number

Beneficiarys Name

Date of Visit

Invoice Number

Service Provided

Gross Amount

Deductible / Co Insurance/ Co Pay/ Discount

Net Amount (to be paid by Daman)




Claims must be organised as per the Statements Serial Number.

Statements Serial Number will appear on each Claim.

Provider code will appear on the statement of account

The billing month will appear on the statement of account

The number of claims in the statement of account should match with the physical
claims submitted

A soft copy of the statement of account in excel format should be sent via mail to
the following E-mail ID: ReceivingUnitmails@damanhealth.ae on the same date
Provider submits its monthly physical claims.

Calculation of Net Amounts:

Deductible is a fixed amount which should be collected by the provider from the
Beneficiary for any covered Health services provided under their Policy. For Example:
Deducible may be applicable to Physician Consultation, Maternity, Laboratory and
Diagnostic Services.

Co-insurance/Co-pay is a percentage that should be collected by the provider from the


Beneficiary on all covered services provided under the Policy. Generally the Co-

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insurance/Co-pay is mentioned on the card and should always be collected on the Net
amount.

Discounts should be calculated on the Gross amount.


Net Amount = Gross (Discount/Co-insurance/Co-pay + Deductible)

Rejected Claims:
If the Provider fails to follow any of the above Claims submission protocols, the batch will be
returned as rejected for necessary corrections.
Resubmission:
All disputed claims (whether partially or fully rejected) should be resubmitted to Daman
within Forty Five (45) calendar days from the date of receipt of payment and/or receipt of
remittance advice or similar document containing the Claim denial code.
Providers can resubmit up to a maximum of three (3) times as outlined in the Standard
Provider Contract [Ref. Article 4.8.2 (b)].
In case of delay in resubmitting a disputed Claim, Daman has the right to completely reject
the payment of all such claims.
Resubmission Requirements:

To fill the Resubmission Form for the disputed Claims with the details

To attach relevant remittance advice along with the Resubmission Form.

To mention on the Resubmission Form the billing period and the cheque received date

To enclose missing information/Reports, including any additional data requested by


Daman to process the Claim.

Mailing Address for Claim submission & Resubmission


The provider should Submit/Resubmit the physical claimsby any courier services to the
following address:
C/O Daman - The Claims Receiving Unit
National Health Insurance Company- Daman
Central Branch, Ground Floor
Airport Road, Abu Dhabi
(Between HSBC & Dubai Islamic Bank buildings)
Tel 02-4173695
Fax 02-6145568
Working Days & Hours:
Sunday to Thursday
8:00 am to 4:00 pm

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thiqa Top Up Billing


1.

Billing for thiqa C1 members with Top Up coverage

2.

Billing for thiqa C2, C3 and C4 members with Top Up coverage

thiqa C2, C3 and C4 cards are not covered in Dubai and NE providers

Services performed will be on Top Up Card (please


please refer to specific Top Up card
Schedule of Benefit for coverage details).
N.B:
Batches Submission & Billing:


thiqa claims under thiqa Batch

Top Up claims under Daman Enhanced Batch

TC1 billing: Different Invoice # for thiqa and thiqa Top Up




thiqa Invoice = 12345

thiqa Top Up Invoice = 12345-TC

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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15. Reconciliation
The Reconciliation is a process that releases Daman from any financial obligations in relation
to Claims that have occurred within the agreed reconciled period. The Provider should sign
with Daman the Reconciliation Agreement and therefore should neither bill nor dispute any
Claims related to the respective reconciled period.

16. Audit
A.

B.

Medical Record Access:

The Provider shall ensure that all covered members sign a Daman consent form
provided by Daman. The Provider shall also ensure that the signed consent form is
maintained along with the Daman members medical records and shall be provided
to Daman upon request. Failure to provide such consent at the time of audit shall
entitle Daman to recover the amount paid for all service(s) rendered to the Daman
member by the Provider.

Daman has the right to access, examine, audit, verify and take copies of its
members original billing and medical records, whether paid or unpaid, inpatient
and outpatient. Medical Records include but are not limited to, patient information,
patient history, medical reports, examination findings, operation/procedure notes,
investigation results or reports, prescriptions for medication, referrals ordered or
received from other Providers, patient management plan, progress notes, consent
forms, discharge summaries and return visits whether in physical and/or electronic
format during or after the term. Billing records include but are not limited to claim
forms, authorisation forms, authorisation approvals, invoices and receipts, in
physical and/or electronic format during or after the term.

In the event that the Provider denies access to the information requested by
Daman during the Audit, the applicable laws in the UAE and/or this Agreement,
Daman shall have the right to reject/recover payment of the respective claims and
immediately terminate this Agreement.

Audit Process

The Provider warrants that all Claims and Prior Authorisationrequests submitted to
Daman for Health Services rendered/to be rendered to a Beneficiary will be true and
accurate to the best of its knowledge and belief.

Daman has the right to audit and re-audit the Providers Medical and Billing
Records either during the tenure of patient confinement/treatment or post discharge
for any Health Service. In the event that the Provider denies access to material
information requested by Daman as per the Rules or this Agreement, Daman shall
have the right to reject/recover payment of the respective claims and immediately
terminate this Agreement.

In the event that Daman suspects Fraud and/or Abuse, the following procedure shall
be applied:
(a)

Daman shall inform the Provider that it suspects that there is a breach of the
Agreement due to suspicion of Fraud and/or Abuse and shall request from the
Provider a written report in respect thereof.

(b)

Whilst investigating the Claim(s) Daman shall be entitled to suspend payments


of all Claims (Past, present or future) to the Provider irrespective of whether
the breach is committed by one Physician or many Physicians (Suspension of
Payments). Daman shall also be entitled to request the Provider cease
providing all new Health Services to a Beneficiary (Suspension of
Services).

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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During the suspension period, the Provider shall cooperate with Daman or any
other party appointed by Daman to minimise disruption to any Beneficiary and
in particular to avoid disruption in the provision of treatment so that any
incomplete/ongoing Health Services for Beneficiaries are completed. Payment
for any incomplete/ongoing health services shall not be collected from the
Beneficiary.
(c)

Within ten (10) calendar days of receipt of the Notice mentioned in clause 8.3
(a) above, the Provider shall conduct an internal investigation of the allegations
and provide Daman with an initial written report, with all relevant
documentations, bills, medical reports and explanations of the outcome of the
investigation and the remedial action to be taken by the Provider.

(d)

Daman shall within ten (10) calendar days of the receipt of the report under
clause 8.3 (c), inform the Provider if it agrees with the findings and/or
recommendations of the Providers report. If Daman does not agree with the
Providers report, it shall inform the Provider of the action to be taken.

(e)

The Provider shall within ten (10) calendar days of receipt of Damans
requirements under clause 8.3 (d) execute the appropriate remedies specified
in its report and/or the actions required by Daman.

(f)

Suspension of Payments and/or Suspension of Services mentioned in clause


8.3 (b) shall remain in effect until Daman is fully satisfied that all due monies
have been recovered.
If Daman confirms its suspicion of Fraud and/or Abuse then it shall report the
matter to the relevant authority and shall be entitled to immediately terminate
the Agreement by sending a written Notice to the Provider without prejudice to
Damans right to claim compensation, damage or any other available remedies
from the Provider.

RECOVERY OF PAYMENT
In the event of any overpayment, duplicate payment or other payment in excess of that to
which the Provider is entitled for rendering Covered Services to the Beneficiary, Daman may
recover the amounts owed by way of offset from current or future payments.
MEDICAL MALPRACTICE
In the event that a medical professional is convicted of Medical Malpractice, Daman shall have
the right to recover from the Provider any amount paid to the Provider in respect of the Claim
submitted to Daman and any associated costs related to the malpractice conviction. Daman shall
also have the right to recover payment for any other Claim arising from the Medical Malpractice
conviction. This provision shall survive the termination of this Agreement.

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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17. Obligation for Addition/Deletion of Branches


All Healthcare Services provided by the Provider to Beneficiaries should be rendered at the
Branch/ premises set out in Appendix B of the Agreement. Daman will not be liable to pay for
any Claim submitted by the Provider if it discovers that the Claim is related to any Healthcare
Services rendered outside the agreed Branches/ premises.
1.

For any addition of Branch/ premises, Provider shall:


a.

Immediately send a written notification to Daman requesting its approval on the


addition. Request for addition should be sent to Daman in writing, stamped and
signed by the signature of the authorised signatory on behalf of the Branch/
premises.

b.

Daman, at its own discretion, will approve or reject the addition of Branch/
premises request and will notify the Provider of its decision.

c.

Provider shall sign an addendum with Daman for addition of Branches/premises.

d.

Only, after receiving the signed addendum for addition of Branch/ premises, that
the Provider will be entitled to render Healthcare Services at the added Branch/
premises. Daman shall not cover any Healthcare Services rendered in the added
Branch/ premises before the provider receives the signed copy of the addendum.

The Provider, its Branches/ premises and any associated providers set out in Appendix
B of the Agreement shall abide by the terms and conditions of the Agreement and shall
be considered jointly and severally liable for any breach of the terms of the Agreement.
2.

For any deletion of Branch/ premises, Provider shall:


a.

Immediately send a written notification to Daman requesting the deletion of the


Branch/ premises. Request for deletion should be sent to Daman in writing,
stamped and signed by the signature of the authorised signatory on behalf of the
Branch/ premises.

b.

Provider, Branch/ premises shall sign a Reconciliation Agreement with Daman for
all outstanding Claims submitted by the Branch/ premises requesting the deletion.

c.

Provider shall sign


Branches/premises.

an

addendum

with

Daman

for

the

deletion

of

the

Deletion of the Branch/ premises will only be effective after the Provider signs a
Reconciliation Agreement with Daman for all Claims related to the deleted Branch/
premises and an addendum to Appendix B of the Agreement for deletion of the Branch/
premises.
Daman will not be liable to pay for any Healthcare Services rendered by the deleted
branch/ premises after being notified by the Provider.

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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18. Daman Contact List


Issue Category/ Department
Concerned

Contact
Number(s)

Mailing Address

Claims Department


Clarifications on claims
adjudication (payment
rejection)

02-614 9722

Claimsqueries@damanhealth.ae

Reconciliation related issues.

E-claims submission and


resubmission

Upload issues.

Rejection of batches (due


to non-compliance & delay
in
submission/resubmission,
etc.)

Receivingunitmails@damanhealth.ae

02-4173651
02-4173696

Provider Relation Department




General Inquiries

New providers (profiling,


contracting, training on
Daman`s policies, products
and schedule of benefits)

Network providers
(clarification of benefit
coverage, amendments, drug
list, queries on update).

Training / Re-Training

PRDqueries@damanhealth.ae

04-4360253

Financequeries@damanhealth.ae

02-614 9709

AuthorisationQueries@damanhealth.ae

02-614 9720

AuthorisationQueries@damanhealth.ae

02-418 4111

Finance Department
 Payments and remittance
advice.
Authorisation Department
 Follow up authorisation
request
 Authorisation status and/or
rejection reason.
 Services which require priorAuthorisation.
 Follow up of thiqa dental
Requests

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Thank You
&
Welcome to Daman Network

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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