Claims Management
The end-to-end claims management cycle is digitized from members’ eligibility checking to service provision, case management, claims adjudication and payment settlement. We ensure better cost containment measures and unparalleled patient's experience.
A. Utilization Management
An Accelerated and Well-Monitored Process
- Online application deployed at healthcare providers’ facilities allowing them to instantly verify members eligibility and submit claims.
- Automating up to 80% of outpatient coverage decisions based on business, policy related and medical rules engine.
- Systematic referral of requests for review and pre-authorization decision based on our expert system engine.
- Fast turnaround time for authorization requests handled by GlobeMed’s approval doctors based on international medical guidelines:
a. Inpatient requests: less than 15 minutes.
b. Outpatient requests: less than 7 minutes.
Constantly Evolving Cost Containment Measures
- Real-time detection of medical, pharmaceutical and coding discrepancies, misuse or potential areas of abuse through our advanced expert system based on sophisticated and flexible algorithms, and renowned data dictionaries adapted to the local market.
- Concurrent reviews with professional doctors roving across the Kingdom reviewing medical files and consulting with attending physicians to ensure that the most appropriate treatment is administered while containing cost.
- Case Management aiming at controlling cost of specific cases while ensuring the proper level of care to insured members following a scoring threshold, taking into consideration the best interest of both the patient and the risk carrier.
Enhanced Patients’ Experience
- Personalized communication with SMS notification to inform patients about the coverage decision.
- Automatic safety checks and alerts based on patients’ medical conditions.
- Minimized patients’ waiting time at healthcare facilities.
B. Referral Management
- Referral management service with automated workflows based on providers capability charts.
- Online handling of referral requests and automated notification of selected providers.
99% of Claims are Received Electronically
- Accommodates a wide range of claims submission’s procedures including real-time submissions, digital uploads or even through direct system integration with healthcare providers, while maintaining the offline manual reception when needed.
- Automatic re-pricing of claims based on provider contractual terms.
- Adjusting claims based on policy rules, and validation of medical necessity through the expert system.
- Medical audit by specialized medical officers reviewing flagged outpatient claims and all inpatient claims.
- Quality assurance over data consistency and integrity, detecting any possible errors prior to claims closing.
D. Third Party Accounting
- Advanced settlement capabilities with highly flexible reporting options accessible by payers, facilitating the payment and reconciliation cycle.
- An e-banking facility for the settlement of dues from payers to providers as an alternative to standard payment methods.
- Streamlined and web-enabled monthly reconciliation with providers allowing them to review adjusted claims and confirm balance.
