INSTITUTIONAL POLICY AND

PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

PURPOSE
This is to notify the facility that those policy holders received can be treated in our institution
or covered but in a given period of time.

DEFINITION
Policy Notifications received from the Insurance Companies are policy contracts of policy
holders under their care. Written in the policy contract/notification are insuring agreement,
policy coverage, the limits of the policy, and the term of the policy and the validity.

PROCEDURE

1. Receiving Of Policy Notification

1.1 All received policy notification either fax or e-mail should have a signature of the
assigned personnel and the DSMC-Insurance Department stamp. The stamped and
signed policy notification should send back to the insurance company as a sign of
confirmation.

1.2 Scan and gather all the received policy notification and compile in one folder per
insurance companies.

1.3 Online policy notification received per insurance companies, are the following:
 Total Care Saudi
 Tawuniya/NCCI
 BUPA
 Saudi Enaya

2. Updating/Adding Policy Contract

2.1 Check Eligibility first before adding/updating policy contract (walk in cardholders).
2.2 Never add any policy contract without validating (re-checking) from the system.

In adding policy contract the important points are listed below:

 NAME OF INSURANCE COMPANY
 NAME OF POLICY HOLDER
 POLICY NUMBER
 STARTING DATE AND EXPIRATION DATE
 CLASS
 APPROVAL LIMIT
 DETUCTIBLE COLLECTED (by percentage/patient’s co-payment)

Page 1 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

2.3 All received policy notification either email or fax should be uploaded in the system of
insurance contract per contract number.

2.4 Cancellation of Received Policy Notification. Upon receiving the notice either fax or email,
changed the expiration date in the system. The expiration date to be input in the system is the
date of the notice received of the cancelled contract or the date that is written in the contract.

3. Process in Updating/Adding Policy Contract in System (Exsys)

From EXSYS System Home Click:

3.1. CREDIT CONTRACT – The page in the Exsys System where to add/update policy
contracts.

Illustration 1.0 This image shows the CREDIT CONTRACTS page.

 After selecting “Credit Contracts” a page will appear (see Illustration 1.1)

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

Illustration 1.1 this image shows the recent added policy contract.

3.1.1. Process on how to search for non-existing/existing policy, as follows:

a. Click Contract Policy Search (see illustration 1.3)
b. A pop-up box will appear. The appeared box is where to re-check if the
policy number is existing or not. Purpose of the re-checking is to avoid data
duplication in the system. (Illustration 1.4)
c. Select Customer Group by clicking the arrow down button. (See Illustration
1.5)
d. Click the arrow down command on the next box for searching of policy
number. (See Illustration 1.6)
e. Then click find or press enter. In case the policy number did not exist after
searching, that’s the only time to add/update the cardholder’s policy scheme.

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

f.

Illustration 1.3

Illustration 1.4 the “arrow down” command symbolizes a search engine

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

Illustration 1.5

POLICY NO.

Illustration 1.6

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

Summary 3.1:

1. Select Contract Policy 2. Select Customer 3. Search for 4. Not Existing Proceed
Search Group Policy Number on the next step.

3.2. INSURANCE COMPANY DETAILS

3.2.1. Contract Adding Procedure:

A. CLICK: “+” button and followed by “ADD GROUP POLICY” as illustrated on 1.7
below. After clicking two buttons successfully, a small box will pop-up. (See illustration
1.8)

1. "+" BUTTON 2. ADD GROUP POLICY

Illustration 1.7

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

 Next step, click arrow down command to select

1. Customer group (e.g, Tawuniya, Bupa)

2. Policy number (you need to be very careful in entering this number because policy
number is used by the receptionist in order to add the insurance coverage to the
patient’s file.
3. Policy scheme/Policy Holder Name - Name of company under the customer group.
(e.g Saudi Telecom Communication/STC)

Illustration 1.8

Illustration 1.8 Illustration shows Customer group, Policy No., Policy description. Click arrow labeled
4 to choose the respective company name you need to add. Enter the policy No. and Policy
description.

Summary:
4. SELECT COSTUMER GROUP: 5. Enter policy 6. Enter Policy
7. Click
number correctly Scheme Save then
(e.g BUPA, Tawaniya, Medgulf) Exit

 Carefully review every detail entered before saving the changes done.
 Once saved, click Exit to go back to Credit Contract Page.

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

3.3. CREDIT CONTRACTS PAGE

 Creating details from the added group policy.

3.3.1. Contract Basic Information

A. Search Costumer Group

Illustration 1.9

B. Enter the Policy Number –insert the policy number that has been added from the “Add Group
Policy”.

 Once the policy number appeared, double click it to enter in the box. (See illustration 1.11.B)

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

DR. SAEED AODH AL ASIRI INSURANCE DEPARTMENT
DSMC- Executive Director
Illustration 1.10.A

Illustration 1.10.B

 Make sure the policy number is under the scheme of the cardholders.
Example: Policy Number 132 is for STC Cardholders

Page 9 of 18
 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

C. CLASS- Choose the appropriate class as what is written on the insurance card or from the policy
contract agreement.

 Classes could be letters, number, color (such as gold, silver bronze etc.,) or letter with number
(such as A1,C2,C3 etc.,).

Illustration 1.12

D. Select ACCOUNT #;

 Account Number must be the same with the Customer Group. (See Illustration 1.13)
 Exception to this rule is for company Total Care Saudi (TCS). Make sure the Account # must be selected is
the sub-company of the cardholder’s policy scheme (See illustration 1.13.B).

Illustration 1.13.A

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

Illustration 1.13.B

E. INCLUDE OPEN EPISODES

 Additional commands to run in the system in a certain area.

Procedure
1. Mark the “PRINT UCAF FORM WITH VISIT” – allows the system to print the
UCAF/DCAF form after securing consultation fee.

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

Illustration 1.14
F. DEDUCTIBLE CARDHOLDERS PAYMENT
 The agreed maximum cardholders’ payment in every visit of every department within follow
up period as per policyholder agreement contract.

Procedure (See Illustration 1.15):

1. Fill in the Max. Patient/Episode – entered in Riyal amount.
2. Fill in Outpatient Section – Discount (%) is the agreed percentage payment of cardholder. Max.
Patient Share is the limit amount payment of the Cardholder within follow-up period. Procedure
1 amount must be congruent to Max Patient Share (Procedure 2) amount. Exception to this rule is
the policy contracts with different amount payment in every Department (Dental, Optical, and
OB-Gyne) as per agreed policy contract.
3. Fill in other Services Deductibles and Medicines Deductibles – in percentage or in Riyals as
per contract.
4. Fill in Days No. and Visits No. – Refers to the “follow-up” period as per MOH and CCHI
Regulations. 14 days is the constant follow-up period. Follow-up will start on the next day.
5. OPD Deductible Type – select the payment type of the cardholder, be in %/SR. Most of the
OPD Deductible is through percentage discount and must be congruent with the Services
Deductibles and Medicines Deductible input.
6. Click Save command. A successful saving is when the notification below on the lower says
“Transaction Complete: 1 record applied and saved”.

Illustration 1.15

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

3.3.2 CONTRACT TARIFF RULES

 Contract Tariff and Rules is the next step after creating the Contract Basic
Information.
 A section in the Exsys Contract Credit where to insert the Expiration Date and the
Approval Limit.
 TARIFF ID – Lists of Main Pricelists of every Customer Group.
 “AMOUNT” - denotes Approval Limit of the cardholder in a certain class within
follow-up period.

Procedure:

A. CONTRACT PERIODS
1. Select Contract Tariff and Rules besides the Contract Basic Information.
2. Choose the appropriate Tariff ID of the cardholders’ customer group. Click OK button.
3. Fill in the box of APPLIES DATE – this refers the date of when the policy contract
created.
4. Fill in the box of TO DATE – refers the expiration date of the policy contract.

Illustration 1.16

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

B. STANDARD RULES
1. Fill in the box of “Amount”/Approval Limit.
2. Selecting of Scope - Scope may differ from company to other company.
BUPA Arabia – Outpatient Day
Episode – All other insurance companies
3. Click save button.

Illustration 1.17

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

3.3.3 NOTES COMMAND

 This area is where to input any special instructions from cardholder’s policy contract. The
special instruction could be viewed and read by the attending physician.
 Special instructions are the inclusions and exclusions of cardholder’s policy scheme.
 The special instructions may differ from class to class.

NOTES

Illustration 1.18

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

Illustration 1.19

Place in the box the special instructions inscribe in the cardholder’s policy. Then click check
command below, automatically the notes has been saved and can be read by the attending physician
through their respective desktop.

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

3.3.4 EXISTING POLICY CONTRACT

 Existed policy numbers/schemes are the contracts are already saved beforehand.
 May differ in some cases, such as:
 Classes from the eligible walk-in cardholders are not yet saved in the Exsys System –
thus add new class.
 Cardholder’s with same policy number and scheme under same Customer Group but
the saved policy contract is already expired – update the expiration date.

Procedure:

A. Process on how to Add /Update Policy Contract with Existing File

1. Click + without selecting the Add Group Policy.
2. Once + clicked, the page will be cleared.
3. Follow the step on 4.2 Credit Contract page.

B. For expired policies:

1. Click the bell as on the corresponding cardholder’s class (see illustration ).

Illustration 1.20

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 INSTITUTIONAL POLICY AND
PROCEDURE

TITLE: POLICY CONTRACT/NOTIFICATION POLICY NUMBER:

APP-INS-03
EFFECTIVE DATE: REVIEW DUE: REPLACES NUMBER:

APPROVED BY: APPLIES TO:

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

2. Re-check all the filled information in every box; make sure the cardholder’s payment
is same with the cardholder’s policy agreement.
3. Select Contract Tariff and Rules.
4. Update the To Date / Expiration Date.
5. Re-check the amount/approval limit.
6. Click save command.

3.3.5. CONTTRACT AGREEMENT INCLUSIONS/ADDENDUMS

A. SAUDI ENAYA
 Saudi Enaya has 2 different contracts for Classes VIP and A and from Class B+, B, C,
C+, CLTD as per agreement contract
 In case cardholder’s class is either VIP or A, select SAUDI ENAYA as a Customer
Group
 SAUDI ENAYA (B+, B, C+, C, CLTD) will be selected as the customer for
cardholder with classes B+, C, C+, CLTD .
 Contract Tariff ID
 Classes VIP and A – Select Saudi Enaya
 Classes B+, B, C+, C, CLTD –Select Saudi Enaya (B+, B, C+, C, CLTD)

B. TOTAL CARE SAUDI (TCS)

 TCS has different contract tariff from Class VIP, A and L to Class B as per contract
agreement
 Contract Tariff ID
 Class VIP, A and L – Select TCS Main Pricelist (Class VIP and A)
 Class B – Select TCS Main Pricelist (Class B)

NOTE: NEVER ATTEMPT TO ADD/UPDATE ON THE PAGE THAT IS NOT WRITTEN IN

THIS PROCEDURE AS THEIR MIGHT BE A DIFFERENCE IN OUTCOME.

APPROVAL
NAME SIGNATURE DATE

Prepared by: DR. IBRAHIM ELSHOURA _____________________ __________________

Reviewed by: DR. ZAYDOON NADI _____________________ __________________

Reviewed by: MS. ABRAR HOUSAWI ______________________ __________________

Approved by: DR. SAEED AWDAH ALASIRI _____________________ __________________

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