INSTITUTIONAL POLICY AND

PROCEDURE

TITLE: EXTERNAL CLAIMS SUBMISSION POLICY NUMBER:

APP-INS-07
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI INSURANCE DEPARTMENT
DSMC- Executive Director FINANCE DEPARTMENT

PURPOSE
Patient’s claims are patient’s medical records to be submitted to their corresponding insurance
company for final review and for reimbursement of medical costs

POLICY
It is the policy of the facility to abide the written contract agreement regarding external claims
submission.

PROCEDURE
1. After submission of patient’s claims to the corresponding insurance companies a discount
payment will be paid to the health care provider as per written in the contract agreement.

2. Institution’s representative accountant will check the bank account monthly if insurance
companies (payer) already pay the prompt discount payment as written in the contract
agreement between two parties.

3. As long as the insurance companies already pay the prompt discount amount (first payment),
insurance manager with the insurance finance department will review the amount paid if
coincides with the contract agreement and to the submitted claims.

4. Insurance finance department is responsible in informing the institution’s insurance manager

regarding payment from the insurance companies.

5. If higher amount will not be paid due to rejection/denied claims a negotiation will take place
between the health care provider and the insurance companies (payers).

6. Negotiation with the insurance companies regarding to the prompt payment discount with
higher medical costs unpaid is the responsibility of the institution’s insurance manager.

7. Any denied or rejected claims received that needs for correction or re-submission should be
abide and insurance manager has the right to appeal to the insurance companies as long as it
is written in the contract agreement the reconsideration between two parties – Health Care
Provider and Insurance Companies.

8. Rejected claims received through courier or e-mail should be forwarded to the insurance
manager for audit.

9. Denied or Rejected medical claims should inform the accountable attending physician to
justify the said rejected claims by sending through e-mails.

10. Accountable attending physician has the right to justify the rejected medical services by
filling up the official letter from the Insurance Department.

11. Justified letter should be sent to insurance department by replying from the e-mail received.

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: EXTERNAL CLAIMS SUBMISSION POLICY NUMBER:

APP-INS-07
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI INSURANCE DEPARTMENT
DSMC- Executive Director FINANCE DEPARTMENT

12. It is the responsibility of the insurance supervisor to print the justified letter and attach the
previous UCAF.

13. Submit the justified medical letter to the insurance companies within 15 days or as per written
contract agreement.

14. Non-refundable services will be reported to the DSMC-HR Department for audit.

APPROVAL

NAME SIGNATURE DATE

Prepared by: DR. IBRAHIM ELSHOURA

Insurance Manager

Reviewed by: DR. ZAYDOON NADI

DSMC-Medical Director

Reviewed by: MS. ABRAR HOUSAWI

Quality Specialist

Approved by: DR. SAEED AWDAH ALASIR

DSMC - Chief Executive Officer

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