From: NEXtCARE KSA - Table of Benefits Center

To: The Network Providers

Table of Benefits for Insurance Coverage
Group Name Contract Insurance Company
Al Bassira Advertising Co MediaCom P/100/01/18/400519 Al Sagr Cooperative Insurance Company

Effective Date: 01/02/2018 Expiry Date: 31/01/2019

You are kindly requested to accept only the following classes allowed to your facility:

Coverage A+
Inpatient Covered
Room type Private
Room Limit (SR) covered in full
Outpatient Covered
Deductible (%) 20%
Max. Deductible (SR) 40
Prior Approval Limit (SR) 1500
Dental Services Covered
Deductible (%) 20%
Max. Deductible (SR) 40
Optical Services Covered
Deductible (%) 20%
Max. Deductible (SR) 40
Maternity Covered
Approval is required for any of the following cases:

1. For all outpatient services exceeding the above

mentioned approval limit according to class. 10. Stress Test/Holter Monitor
2. For all Dental services 11. Ophthalmic fluorescent angiography
3. For all Maternity services 12. Chemotherapy & Radiotherapy
4. For all day-case surgeries 13. M.R.I
5. For all Optical services 14. Physiotherapy
6. For all Inpatient Cases 15. C.T. Scan
7. More than one month chronic medications. 16. Osteodensitometry
8. Abdominal-pelvic Ultrasound 17. Cardiac Scintigraphy
9. Echo and Doppler Radiology scan 18. Hearing Aids / Ear Piercing / Circumcision
NOTES
• Group has the standard schedule and benefits of CCHI policy, coverage and exclusions.
• All approvals under approval limit are conditionally approved as per CCHI Regulations.
• Dental Services include: Consultation, Filling, RCT, Extraction, simple Xray, medications, Gum
treatment
• Optical Services include: Lenses (glasses), Frames.
• Vaccinations are covered as per MOH

For further clarifications, please contact our Help Desk at 920003055

Confirmation to be sent to SAUDI NEXtCARE at fax : 013-8933101, email: TOB-KSA@nextcarehealth.com
We hereby confirm that policy has been activated ‫نؤكد لكم بأنه تم تفعيل الوثيقة للفئات المؤمنة‬
into our system for the above mentioned classes. ‫المذكورة أعاله وذلك على أن يتم خدمة األشخاص‬
Services to its insured members is to be provided as ‫المؤمنين حسب تغطيات وشروط واستثناءات مجلس‬
per CCHI coverages exclusions. . ‫الضمان الصحي التعاوني‬

Provider's Authorized Officer : :‫الموظف المــفوض‬

Date: :‫التاريخ‬
Signature : : ‫التوقيع‬
Stamp : :‫الختم‬

29/01/2018@14:50 Al Sagr TOB.xlsm