HEALTH INSURANCE NOTIFICATION LETTER

DATE : 06-JAN-2015 06-JAN-2015 : ‫التاريخ‬

FROM : MEDICAL NETWORK DEPARTMENT ‫قسم الشبكة الطبية‬ : ‫من‬

TO : HAI AL JAMEA HOSPITAL ‫مستشفى حي الجامعة‬ : ‫الى‬

MCMS ID : 025000017 025000017 : ‫كود الحاسب اآللي‬

SUBJECT : HEALTH INSURANCE NOTIFICATION LETTER ‫خطاب تعميد الخدمة الصحية‬ : ‫الموضوع‬

EFFECTIVE DATE : 01-JAN-2015 01-JAN-2015 :‫يطبق بدءًا من تاريخ‬

Please accept Malath clients holding Malath ‫الرجاء استقبال عمالء مالذ حاملين بطاقات التامين‬
health insurance cards as per the below ‫الصحي على حسب الفئات ادناه‬
mentioned classes.

‫الرجاء استقبال بطاقات التامين بالفئات المذكوره ادناه‬

PLEASE ACCEPT HEALTH CARE CARDS BY CLASSES AS MENTIONED BELOW

CLASSES VVIP VIP A+ A

‫الرجاءعدم استقبال بطاقات التامين بالفئات المذكوره ادناه‬

PLEASE DO NOT ACCEPT HEALTH CARE CARDS BY CLASSES AS MENTIONED BELOW

CLASSES B+ B C+ C D D Retail

All direct exceptional notifications by exceptional ‫ أو‬/ ‫جميع التعميدات االستثنائية المباشرة لوثائق استثنائية و‬
polices and / or specific members remain valid ‫أفراد محددين تظل سارية المفعول بدون تغيير ( طبقا لما ورد في‬
without changes ( As per the details mentioned in every ) ‫كل تعميد استثنائي على حدة‬
exceptional notification )

CARD SAMPLE

SYED M ALAM
2299128146-100-01 SEX M AGE 30
POLICY HOLDER
NSD HOLDING COMPANY
POLICY NUMBER EFFECTIVE DATE EXPIRY DATE
9000999 1/12/2014 30/11/2015
DEDUCT / CO-INS (20%) MAX. 100 SR CLASS - A PLAN -18

GOLD

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SUMMARY TABLE OF ACCEPTED CLASSES AND PLANS 01/01/2015
CARD COLOURS PLATINUM GOLD
CLASSES VVIP VIP A+ A
ROOM TYPE REGULAR SUITE PRIVATE ROOM
NIL 1 6 11 16
10% MAX 100 SR 2 7 12 17
20% MAX 100 SR 3 8 13 18
10 SR 4 9 14 19
20 SR 5 10 15 20

15% MAX 100 SR 46 51 56 61

15 SR 47 52 57 62
30 SR 48 53 58 63
40 SR 49 54 59 64
50 SR 50 55 60 65

10% MAX 50SR 91 109 127 145

10% MAX 40SR 92 110 128 146
10% MAX 30SR 93 111 129 147
10% MAX 20SR 94 112 130 148
10% MAX 15SR 95 113 131 149
10% MAX 10SR 96 114 132 150

15% MAX 50SR 97 115 133 151

15% MAX 40SR 98 116 134 152
15% MAX 30SR 99 117 135 153
15% MAX 20SR 100 118 136 154
15% MAX 15SR 101 119 137 155
15% MAX 10SR 102 120 138 156
PLAN NUMBER WITH
CO INSURANCE /
DEDUCTABLE RANGE. 20% MAX 50SR 103 121 139 157
20% MAX 40SR 104 122 140 158
20% MAX 30SR 105 123 141 159
20% MAX 20SR 106 124 142 160
20% MAX 15SR 107 125 143 161
20% MAX 10SR 108 126 144 162

20% MAX 75SR 253 254 255 256

20% MAX 70SR 262 263 264 265
20% Max. SR. 25 271 272 273 274
15% Max. SR. 75 280 281 282 283
15% Max. SR. 70 289 290 291 292
15% Max. SR. 25 298 299 300 301
10% Max. SR. 75 307 308 309 310
10% Max. SR. 70 316 317 318 319
10% Max. SR. 25 325 326 327 328
5% Max. SR. 100 334 335 336 337
5% Max. SR. 75 343 344 345 346
5% Max. SR. 70 352 353 354 355
5% Max. SR. 50 361 362 363 364
5% Max. SR. 40 370 371 372 373
5% Max. SR. 30 379 380 381 382
5% Max. SR. 25 388 389 390 391
5% Max. SR. 20 397 398 399 400
5% Max. SR. 15 406 407 408 409
5% Max. SR. 10 415 416 417 418

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 PRE AUTHORIZATIONS
ALL COVERAGES,TERMS,CONDITIONS AND EXCLUSIONS ARE UNDER CCHI STANDARD POLICY.
Non Emergency Cases or Services that are required Malath Pre-Authorization
Out-patient Services In-Patient Services
1) Ant-Natal Care 1st visit only 1) All medical cases need hospitalization or Surgery
2) Chronic Medications for more than one month up to
2) Chronic Medications for more than one month up to three months
three months
3) Dental Benefit 3) Deliveries and abortions
4) Frames & Lenses excluding contact lenses 4) Physiotherapy
5) Hearing Aids 5) Acquired Heart Valve Disease
6) Physiotherapy starting from the second session 6) Organ Donor Operation
7) Acute Psychiatric Diseases 7) Alzheimer Disease
8) Acquired Heart Valve Disease 8) Autism
9) Organ Donor Operation 9) National Programme for early detection of disabilities
10) Alzheimer Disease in newborns
11) Autism 10) Disability Cases
12) National Programme for early detection of disabilities in newborns
13) Disability Cases

Emergency Cases or Services do not require Pre-authorization or Pre-approval

All emergency medical cases/services do not require Pre-authorization or Pre-approval from Malath's medical
center, this will includs the use of Ambulance within the city limits, if medically justified.

However, please provide us with the necessary notifications related to those cases/services to be
Authorized/Approved by Malath's medical center within 24 hours the time of starting treatment.

INFORMATIONS
TEL : 01-2939955 , EXT: 7172, 7376, 7044, 7374 / FAX : 01-4628400
NETWORK DEPT.
email : providers@malath.com.sa

DR.ASHRAF ,MR. SUHAIL , DR. TARIQ , MR.ALAM , MR.RADI , MR.AHMED

TEL : 01-2939955 , EXT: 7171,7173,7172,7177,7175 / FAX : 01-2939966 email:

APPROVAL DEPT.
approval1@malath.com.sa

DENTAL FAX: 01-2937700

DR.MOHAMMED, DR.AHMED, DR.MAZIN, MR.MARK

CLAIMS DEPT. TEL : 01-2939955 , EXT: 7071/ FAX : 01-4661015

DR.AMEER SARHAN

T0LL FREE LINE : 8001280077

On behalf of
Provider Name:………………………………….

Signature: .....…..…………………………………
Dr Ashraf Hussiny Salem
Medical Network Manager Date: ….……………………………..……………
No need for stamping as this notification is
automatically generated Stamp: ....…………………………………………

PLEASE SEND YOUR CONFIRMATION TO FAX - 011-4628400

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