Page 17 - C.Journal 3rd edition

Claims Journal 3rd Edition Claims Journal 3rd Edition

C.M.E Guest Corner

Prepared by Marwa Ibrahem Prepared by Esraa Shahin & Raneem Wardah

No Preauthorization Required Tips

With all Sublimits we must attach PA # even if it is (No PA required).

CLINICAL PRESENTATION DIAGNOSIS AND MONITORING
• Maternity:
The purpose for first ANC visit is to check if the patient is eligible for maternity coverage or not.
-No PA required even if ICD code in PA is ???? –> consider it as first ANC.

• Physiotherapy, MRI & CT:
1- Patient with limited schemes (ex: 1000,1500,2000 or 3000):
a. If ther is “ No PA required” -> adjudicate medically
b. If there is no PA # -> reject by 140.

2- Patient with unlimited schemes (ex: VIP, Diamond):
In both cases (No PA required or there is No PA) -> adjudicate medically.

• Dental:

TREATMENT No PA required -> attach PA because the amount of the claim will be deducted from the sublimit.
Levothyroxine (drug of choice)

- Dosing • Supportive devices, Nebulizers, Thermometer & ETC:
(1) In otherwise healthy adults, 1.6 mcg/kg (use ideal body weight) per day. “ No PA required “ -> BUPA cover the basic type:
(2) In patients 50–60 years of age, consider 50 mcg/day. - If it is an expensive device – reject by 122.
(3) In those with existing cardiovascular disease, consider 12.5–25 mcg/day. - If Reasonable price – adjudicate medically.
(4) Can increase or decrease in 12.5- to 25-mcg/day increments
(5) Daily requirements are higher in pregnancy. o Devices (Glucometer,nebulizer,wheel chair and thermometer) we have to change the
benefit head to H12 ; And for hearing aids B1.

• Uncovered medication:
1- No PA required -> reject by 145
2- If it is approved -> “till Feb 2017 Batches” ->attach the PA and approve
->“After Feb 2017 Batches” -> attach the PA, approve and escalate.

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