Beruflich Dokumente
Kultur Dokumente
Manual Outlines
1.
Introduction ................................................................................................................ 3
2.
3.
4.
5.
Non-Discrimination .....................................................................................................12
6.
7.
8.
9.
10.
Authorisations ............................................................................................................52
11.
12.
E-Claims....................................................................................................................59
13.
14.
Reconciliation .............................................................................................................65
15.
Audit .........................................................................................................................65
16.
17.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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1.
Introduction
The Provider Manual is a document designed to outline the administrative procedures,
requirements and specific instructions that need to be completed by Network Providers when
rendering Healthcare Services to Beneficiaries.
This Provider Manual shall be read in conjunction with the Standard Provider Contract signed
between National Health Insurance Company Daman (PJSC) (hereinafter referred to as
Daman) and Provider. If not specifically defined herein, all definitions used in the Provider
Manual are the same as in the Standard Provider Contract.
This Provider Manual is furnished to all Network Providers that are located in Dubai and
Northern Emirates only
Daman may modify the Provider Manual by sending a written notification to Network
Providers thirty (30) calendar days prior to such modification.
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2.
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B.
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C.
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3.
Existing Name
thiqa
thiqa C1
Exclusive 1
NW1
NW UAE/ AD Public
& Private
Premier
Premier
Exclusive 1
NW1
Premier Plus
Premier Plus
Exclusive 1
NW1
Premier Ext
Premier Ex
Exclusive 1
NW1
Premier TC1
Premier TC1
Exclusive 1
NW1
Premier TC2
Premier TC2
Exclusive 1
NW1
Premier TC3
Premier TC3
Exclusive 1
NW1
Premier TC4
Premier TC4
Exclusive 1
NW1
Global
Enhanced Platinum
Exclusive 1
NW1
Exclusive 1
NW1
Global Plus
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
International
Enhanced Gold
Exclusive 1
NW1
International Ext
Enhanced Gold Ex
Exclusive 1
NW1
Exclusive 1
NW1
International Plus
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
Regional
Enhanced Silver
Comprehensive 2
NW1
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Regional Ext
Enhanced Silver Ex
Comprehensive 2
NW1
Regional Plus
Comprehensive 2
NW1
Comprehensive 2
NW1
Comprehensive 2
NW1
Comprehensive 2
NW1
Comprehensive 2
NW1
UAE
Enhanced Bronze
Comprehensive 3
NW2
UAE Ext
Enhanced Bronze Ex
Comprehensive 3
NW2
UAE TC1
Enhanced Bronze TC 1
Comprehensive 3
NW2
UAE TC2
Enhanced Bronze TC 2
Comprehensive 3
NW2
UAE TC3
Enhanced Bronze TC 3
Comprehensive 3
NW2
UAE TC4
Enhanced Bronze TC 4
Comprehensive 3
NW2
UAE Limited
Core Silver
Essential 5
NW5
UAE Optima
Core Silver R
Essential 5
NW5
Basic Plus
Core Bronze
Essential 5
NW5
TC Plus 2
TC Plus 2
TC Plus 2
NW1
TC Plus 3
TC Plus 3
TC Plus 3
NW1
TC Plus 4
TC Plus 4
TC Plus 4
NW1
Core Chrome IP
Core Chrome IP
Essential 5
Hospitals only
NW5
Core Bronze IP
Core Bronze IP
Value 3 Hospitals
only
NW2
Premier SG
Premier SG
Global SG
International SG
Regional SG
UAE SG
CarePlatinum
Enhanced Platinum SG
CareGold
Enhanced Gold SG
CareSilver
Enhanced Silver SG
Care Bronze
Enhanced Bronze SG
Core Silver R SG
UAE Optima SG
Existing Network
New Network
Names within
Names within UAE
UAE
Exclusive 1
NW1
Exclusive 1
NW1
Exclusive 1
NW1
Comprehensive 2
NW1
Comprehensive 3
NW2
Essential 5
NW5
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4.
Patient Consent
Prior to submitting any Claims related to Healthcare Services rendered to Beneficiaries, the
Provider shall ensure that the below Medical Consent Form (the Medical Consent Form) is
signed by the Beneficiary and enclosed in his medical file. The Medical Consent Form must be
filed/made available in the patients Medical Record at all times.
Medical Consent Form allows Daman to access Beneficiaries Medical Records at the Network
Providers facility and in the event Daman discovers that a medical file does not contain a
signed copy of the Consent Form, Daman will be entitled to recover from the Provider all
payments related to this file.
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5.
Non-Discrimination
The Provider shall not discriminate in any way against any of Damans members with respect
to the provisions of the healthcare services on account of race, religion, creed, color, national
origin, sex, age, marital status, physical handicap, political beliefs or affiliation, or
membership in any lawful organization.
The Provider should provide the healthcare services to Damans members without regard to
coverage status in the same professional manner and with the same degree of care, skill and
diligence as the Providers provide to other patients, and in accordance with generally
accepted scientific and technical principles and standards of ethics.
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6.
Receiving Members
Whenever a Healthcare Service is sought by a Beneficiary, the Network Provider should
adhere to the following steps/procedures:
a)
b)
c)
d)
e)
f)
Receive
e the payment from Daman
Receiving Top-up
up Members
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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7.
Daman Forms
Below are the Forms in relation to Healthcare Services
Network Providers are required to comply with below listed Daman Forms prior to rendering
any Healthcare Services
For Emergency Services, Provider must render the Healthcare Services and seek
authorisation within 24 hours from providing the Emergency Services.
Daman Forms are segregated as following:
I.
II.
b.
c.
d.
e.
f.
g.
h.
i.
Approval Forms:
a.
b.
c.
b.
c.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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I.
a.
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b.
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c.
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d.
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e.
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f.
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is almost perfection.
Grade 2
is for greater irregularities which normally do not need treatment for health
reasons:
Upper front teeth that protrude less than 4 mm more than normal.
Reversals of the normal relationship of upper teeth which only interfere with normal
function to a minor degree; by less than 2 mm
Irregularity of teeth which are less than 4 mm out of line
Open bites of less than 4 mm
Deep bites with no functional problems.
Grade 4
is for more severe degrees of irregularity and these do require treatment for
health reasons:
When teeth cannot come into the mouth normally because of obstruction by crowding,
additional teeth or any other cause.
A large number of missing teeth.
Upper front teeth that protrude more than 9 mm
Lower front teeth that protrude in front of the upper more than 3.5 mm and where there
are functional difficulties too
Cranio-facial anomalies such as cleft lip and palate.
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g.
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h.
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i.
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II.
Approval Forms:
a.
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b.
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c.
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2.
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3.
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IV.
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8.
2-
Go to Member Validity.
3-
Member Number
b.
c.
Service Date.
4-
5-
The below message will be displayed for Beneficiarys validation: Member is valid/ not
valid.
6-
If the Beneficiary is valid then SOBs & Exclusions list will be displayed.
7-
Network Provider must be able to view the current SOBs and general exclusions related
to the Beneficiary.
8-
In case the Network Provider enters the current date for deleted Beneficiary with an
expired card, the system will give a message Member expired or deleted.
9-
In case the Network Provider attempts to enter a future date then a message will
appear and no SOBs, Exclusions list will be displayed.
10-
11-
After display of the SOBs and Exclusions list the following disclaimer should appear:
Further to displayed SOBs/Exclusion List, kindly take into consideration HAAD/Daman
circulars which were effective at the time of the service date.
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9.
2-
Go to Medical Provider
3-
4-
5-
The below message will be displayed for Beneficiarys validation: Member is valid/ not
valid.
6-
If the Beneficiary is valid, please print the Validity receipt to be used forAuthorisation (if
required) and Billing Purposes.
7-
If the Beneficiary is not valid, please call Daman Call Center (800 432626) for further
clarification
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10. Authorisations
For Emergency Services, Provider must render the Healthcare
Authorisation within 24 hours from providing the Emergency Services.
Services
and
seek
Network Providers are required to comply to use Daman Forms before rendering any
Healthcare Service.
All Pre Authorisation Requests should be sent to Authorisation Department by Fax as per the
Number specified on the form except for thiqa Dental Pre-Authorisation Requests which are
sent through E-mail to AuthorisationQueries@damanhealth.ae
Providers that signed Standard Provider Contract E- Claims should send the Pre-authorisation
requests withrhe specified CPT Codes for pre-approval
The following Plans are exempted from Authorisation:
PREMIER PLAN
1. Crown Prince Court
2. Emirates Nuclear Energy Corporation (ENEC)
3. Federal Authority for Nuclear Regulation
4. General Secretariat of Executive Council
5. Ministry Of Presidential Affairs
6. Mubadala Company
7. Technology Development Committee
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The following procedures excluding Medications require Pre-Authorisationby the Network Providers:
Pre- Authorisation
Core Silver
(Previously UAE
Limited Plan)
Core Silver R
(Previously UAE
Optima)
Enhanced Bronze
(Previously UAE
Plan)
Enhanced Bronze Ex
(Previously UAE
Extended Plan)
Enhanced Silver Ex
(Previously Regional
Extended)
Dental
Core Chrome Ex
(Previously Abu
Dhabi Extended
Plan)
Medical Checkup
Podiatry Services
Alternative Medicine
Chiropractic Services
Core Bronze
(Previously Basic
Plus)
Rehabilitation
Physiotherapy
Dietician
Psychiatry
Endoscopies
Home Nursing
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Enhanced Gold
(Previously
International Plan)
Enhanced Gold Ex
(Previously
International
Extended)
Enhanced Platinum
(Previously Global
Plan)
Enhanced Platinum
Plus (Previously
Global Plus)
Premier Plan
Premier Extended
thiqa Plan
(HCT ,
ZU, UAEU)
Enhanced Silver
(previously Regional
Plan)
Enhanced Bronze
TC2 / TC3 / TC4
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Enhanced Platinum
Plus (Previously
Global Plus) TC2 /
TC3 / TC4
The Network Provider is to fill 1 thiqa Authorisation Request carrying both member
IDs and send it to Daman in a single fax/email
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Medications Exceeding
30 days
Plans Exempted
fromAuthorisation
ENHANCED SILVER PLUS
(PREVIOUSLY REGIONAL PLUS)
Mubadala Company
Federal Authority for Nuclear
Regulation
Emirates Nuclear Energy
Corporation (ENEC)
ENHANCED GOLD PLUS
(PREVIOUSLY INTERNATIONAL
PLUS)
Mubadala Company
Core Bronze
(Previously Basic Plus)
Core Chrome Ex
(Previously Abu Dhabi Extended
Plan)
All Other Plans
Core Silver
(UAE Optima)
Mubadala Company
PREMIER PLAN
Crown Prince Court
Core Silver R
(Previously UAE Optima)
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Dental Prescription
1.
2.
3.
Psychiatric Medication
1.
2.
3.
4.
5.
6.
7.
TC4
8.
Fill the Chronic Medication Form with the appropriate information which
includes the Patients Information, Drug Name, Strength, Dosage, Duration of
Treatment, Total Number of boxes and Total AED Price; and
2.
Send by fax with a copy of the Beneficiary Membership Card and the Chronic
Medication Form to the AuthorisationDepartment on 02-6149777 requesting an
approval;
3.
For unregistered providers, please register with a user name and password to access the
tool
To search for Authorisations for Enhanced and Basic members please follow
www.damanhealth.ae
Below are the instructions regarding how to perform the search (please note it is important
to follow the instructions as provided by Daman):
1. Go to More then Authorisation Dashboard.
2. The Provider will have the following Search options to filter authorisations
Date From and To is a mandatory field for search in provider search.
Provider can view authorisations issued within the last 90 days.
In case the provider has more than 100 authorisations in the past 90 days then
the following disclaimer will be shown to the provider;
Only 100 records can be displayed, in case you
need to check for further
records please use the above filtering options.
The provider may choose not to filter as well. This will display all authorisations
records.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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5. In case no authorisation exists for the member then the following disclaimer will be
displayed for the provider
No records to display
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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13. E-Claims
All Network Providers shall submit their Claims electronically to Daman via the following link:
www.eclaimlink.ae
A.
Submission:
1-
All Providers must submit their Claims no later than thirty (30) calendar days from
the end of the month of Healthcare Services provided to the Beneficiary.
2-
Receiving requirements:
a.
b.
c.
d.
B.
C.
INS026
INS026-H100-MAR2013-OP-ENH-SUB-01
01
The Network Provider shall adjust all electronic transactions related to PriorPrior
Authorisation
uthorisationRequests / Claims Submission with the Payer ID listed in below
matrix based on the submitted product.
Resubmission:
Within Forty Five (45) calendar days from the date of receipt of remittance advice.
Resubmission types:
The Provider shall segregate the resubmission of XML files by Plan by Resubmission
type.
The following are Resubmission types:
Correction Type:
o
This type is applicable in case the Provider conducts any changes within the
claim
itself
(for
example
Service
Code/CPT
Code/CPT-4
Code/Price/A
Code/Price/AuthorisationNumber/Diagnosis
Number/Diagnosis Code/etc.).
This type shall be treated as a new claim. Therefore the Provider should
resubmit and include all activities with amounts (pai
(paid/unpaid).
d/unpaid).
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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The Provider shall resubmit the contested services and contested amounts
only along with the related unpaid amount (not to be treated as a fresh
claim).
The Provider shall add his comments by specifying the rejected service along
with his justification for rendering the Service (Providers can attach PDF
documents e.g. Medical Report/ Discharge Summary/etc.).
Example: TPA023-H100-MAR2013-OP-TQA-RESUB-INTERNAL COMPLAINT
N.B.: Correction and internal complaint must be resubmitted with Daman
claim ID made available to providers along with the Remittance Advice sent
back with respect to the initial submissions.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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One itemised Invoice with all services provided per visit or different invoices for
different services.
One itemised Invoicewith all services provided during Admission or different Invoices for
different services.
Discharge Summary.
All submitted Claims must have the Beneficiarys signature & the Physicians
signature and stamp.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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The provider should include the In-house Pharmacy billing related to Hospital /
Medical Center along with the Out-patient / In-patient invoice to make it as a
single Encounter under one Claim.
Serial Number
Beneficiarys Name
Date of Visit
Invoice Number
Service Provided
Gross Amount
The number of claims in the statement of account should match with the physical
claims submitted
A soft copy of the statement of account in excel format should be sent via mail to
the following E-mail ID: ReceivingUnitmails@damanhealth.ae on the same date
Provider submits its monthly physical claims.
Deductible is a fixed amount which should be collected by the provider from the
Beneficiary for any covered Health services provided under their Policy. For Example:
Deducible may be applicable to Physician Consultation, Maternity, Laboratory and
Diagnostic Services.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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insurance/Co-pay is mentioned on the card and should always be collected on the Net
amount.
Rejected Claims:
If the Provider fails to follow any of the above Claims submission protocols, the batch will be
returned as rejected for necessary corrections.
Resubmission:
All disputed claims (whether partially or fully rejected) should be resubmitted to Daman
within Forty Five (45) calendar days from the date of receipt of payment and/or receipt of
remittance advice or similar document containing the Claim denial code.
Providers can resubmit up to a maximum of three (3) times as outlined in the Standard
Provider Contract [Ref. Article 4.8.2 (b)].
In case of delay in resubmitting a disputed Claim, Daman has the right to completely reject
the payment of all such claims.
Resubmission Requirements:
To fill the Resubmission Form for the disputed Claims with the details
To mention on the Resubmission Form the billing period and the cheque received date
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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2.
thiqa C2, C3 and C4 cards are not covered in Dubai and NE providers
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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15. Reconciliation
The Reconciliation is a process that releases Daman from any financial obligations in relation
to Claims that have occurred within the agreed reconciled period. The Provider should sign
with Daman the Reconciliation Agreement and therefore should neither bill nor dispute any
Claims related to the respective reconciled period.
16. Audit
A.
B.
The Provider shall ensure that all covered members sign a Daman consent form
provided by Daman. The Provider shall also ensure that the signed consent form is
maintained along with the Daman members medical records and shall be provided
to Daman upon request. Failure to provide such consent at the time of audit shall
entitle Daman to recover the amount paid for all service(s) rendered to the Daman
member by the Provider.
Daman has the right to access, examine, audit, verify and take copies of its
members original billing and medical records, whether paid or unpaid, inpatient
and outpatient. Medical Records include but are not limited to, patient information,
patient history, medical reports, examination findings, operation/procedure notes,
investigation results or reports, prescriptions for medication, referrals ordered or
received from other Providers, patient management plan, progress notes, consent
forms, discharge summaries and return visits whether in physical and/or electronic
format during or after the term. Billing records include but are not limited to claim
forms, authorisation forms, authorisation approvals, invoices and receipts, in
physical and/or electronic format during or after the term.
In the event that the Provider denies access to the information requested by
Daman during the Audit, the applicable laws in the UAE and/or this Agreement,
Daman shall have the right to reject/recover payment of the respective claims and
immediately terminate this Agreement.
Audit Process
The Provider warrants that all Claims and Prior Authorisationrequests submitted to
Daman for Health Services rendered/to be rendered to a Beneficiary will be true and
accurate to the best of its knowledge and belief.
Daman has the right to audit and re-audit the Providers Medical and Billing
Records either during the tenure of patient confinement/treatment or post discharge
for any Health Service. In the event that the Provider denies access to material
information requested by Daman as per the Rules or this Agreement, Daman shall
have the right to reject/recover payment of the respective claims and immediately
terminate this Agreement.
In the event that Daman suspects Fraud and/or Abuse, the following procedure shall
be applied:
(a)
Daman shall inform the Provider that it suspects that there is a breach of the
Agreement due to suspicion of Fraud and/or Abuse and shall request from the
Provider a written report in respect thereof.
(b)
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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During the suspension period, the Provider shall cooperate with Daman or any
other party appointed by Daman to minimise disruption to any Beneficiary and
in particular to avoid disruption in the provision of treatment so that any
incomplete/ongoing Health Services for Beneficiaries are completed. Payment
for any incomplete/ongoing health services shall not be collected from the
Beneficiary.
(c)
Within ten (10) calendar days of receipt of the Notice mentioned in clause 8.3
(a) above, the Provider shall conduct an internal investigation of the allegations
and provide Daman with an initial written report, with all relevant
documentations, bills, medical reports and explanations of the outcome of the
investigation and the remedial action to be taken by the Provider.
(d)
Daman shall within ten (10) calendar days of the receipt of the report under
clause 8.3 (c), inform the Provider if it agrees with the findings and/or
recommendations of the Providers report. If Daman does not agree with the
Providers report, it shall inform the Provider of the action to be taken.
(e)
The Provider shall within ten (10) calendar days of receipt of Damans
requirements under clause 8.3 (d) execute the appropriate remedies specified
in its report and/or the actions required by Daman.
(f)
RECOVERY OF PAYMENT
In the event of any overpayment, duplicate payment or other payment in excess of that to
which the Provider is entitled for rendering Covered Services to the Beneficiary, Daman may
recover the amounts owed by way of offset from current or future payments.
MEDICAL MALPRACTICE
In the event that a medical professional is convicted of Medical Malpractice, Daman shall have
the right to recover from the Provider any amount paid to the Provider in respect of the Claim
submitted to Daman and any associated costs related to the malpractice conviction. Daman shall
also have the right to recover payment for any other Claim arising from the Medical Malpractice
conviction. This provision shall survive the termination of this Agreement.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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b.
Daman, at its own discretion, will approve or reject the addition of Branch/
premises request and will notify the Provider of its decision.
c.
d.
Only, after receiving the signed addendum for addition of Branch/ premises, that
the Provider will be entitled to render Healthcare Services at the added Branch/
premises. Daman shall not cover any Healthcare Services rendered in the added
Branch/ premises before the provider receives the signed copy of the addendum.
The Provider, its Branches/ premises and any associated providers set out in Appendix
B of the Agreement shall abide by the terms and conditions of the Agreement and shall
be considered jointly and severally liable for any breach of the terms of the Agreement.
2.
b.
Provider, Branch/ premises shall sign a Reconciliation Agreement with Daman for
all outstanding Claims submitted by the Branch/ premises requesting the deletion.
c.
an
addendum
with
Daman
for
the
deletion
of
the
Deletion of the Branch/ premises will only be effective after the Provider signs a
Reconciliation Agreement with Daman for all Claims related to the deleted Branch/
premises and an addendum to Appendix B of the Agreement for deletion of the Branch/
premises.
Daman will not be liable to pay for any Healthcare Services rendered by the deleted
branch/ premises after being notified by the Provider.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Contact
Number(s)
Mailing Address
Claims Department
Clarifications on claims
adjudication (payment
rejection)
02-614 9722
Claimsqueries@damanhealth.ae
Upload issues.
Receivingunitmails@damanhealth.ae
02-4173651
02-4173696
General Inquiries
Network providers
(clarification of benefit
coverage, amendments, drug
list, queries on update).
Training / Re-Training
PRDqueries@damanhealth.ae
04-4360253
Financequeries@damanhealth.ae
02-614 9709
AuthorisationQueries@damanhealth.ae
02-614 9720
AuthorisationQueries@damanhealth.ae
02-418 4111
Finance Department
Payments and remittance
advice.
Authorisation Department
Follow up authorisation
request
Authorisation status and/or
rejection reason.
Services which require priorAuthorisation.
Follow up of thiqa dental
Requests
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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Thank You
&
Welcome to Daman Network
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
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