عناية تي بي ايه (ش.ز.م.م.)

WE WILL HELP YOU

FREQUENTLY ASKED QUESTIONS

1 Is INAYAH an Insurance Company?

INAYAH is a TPA (Third Party Administrator) that functions as an intermediary between the insurance provider and the policyholder. The main function of TPA is processing and settlement of medical claims. We are inhouse Claim Administrator for National Life & General Insurance Company SAOG.

2Services Offering being Inhouse Claim Administrator

1. Member enrolment and issuance of health card\r\n2. Cashless service facility at network facilities up to the authorized limit as per policy terms & conditions\r\n3. Reimbursement Claim Processing.\r\n4. Call center service 24 X 7 through toll free Number.\r\n5. Customer service support\r\n6. Mobile Application for Member\r\n

3 What is a Claim?

Claim is the payment made by the insurer to the insured or claimant on the occurrence of the event specified in the contract, in return for the premiums paid for the insured.

4How to submit a reimbursement claim?

You can submit a reimbursement claim to your respective insurance company through your HR/Insurance Brokers or Email to reimbursements@nlicgulf.com.

You can also submit a reimbursement claim either through the INAYAH website www.inayahtpa.com or through the Mobile App available on Google Play and Apple Store. a. Go to www.inayahtpa.com or NGLIC-Care b. Register or log in through your user name and password c. Go to “Claims” d. Go to “Submit New Claim” and make sure you have on hand the following: - Complete details of the availed medical services, such as the healthcare provider name, service date and description and the physician name. - All necessary supporting documents, including the medical report, itemized bills and original receipts. Since required documents differ from one country to another and from one service type to another, for a complete list of required documents, please check “What are the required documents for Reimbursement Claim submission?” After completing all required information, follow these steps: a. Complete your claim information b. Upload or capture all required supporting documents c. Click "Submit Claim" to complete the process After you submit your completed claim form, you will receive an email notification confirming the successful submission.

5 What is the Time Limit to submit a Reimbursement claim?

You must submit the claim documents within 60 days from the date of treatment for the treatment availed in UAE. For the treatment availed outside UAE, the claim documents must be submitted within 90 days from the date of treatment.

6 Can I Receive Cash payment for my Reimbursement Claim?

No, we do not provide any cash payments for reimbursement claims.

7 If my Claim is rejected? How will I be Notified?

In case your claim gets rejected due to incomplete submission or ineligibility, you will be notified by the Reimbursement team through email and a statement of account will be sent to you with explanation of benefit stating the reason of rejection. Please provide a valid email address in the claim form where the team will be able to reach you.

8 What is the rate of Exchange applied on the International Medical Claim Reimbursement?

Actual rate of exchange at the time of medical expense incurred is taken for reimbursement of international medical claim expenses.

9 Can I visit a provider outside my network?

Yes, you can only if as per your Insurance Policy Terms and Conditions you are allowed to use a non-network provider for eligible services. However, this is not recommended as you will be required to pay all bills and then claim back eligible/possible amounts.

10 What are the required documents for Reimbursement Claim submission?

01. Duly filled INAYAH Reimbursement Claim Form (mandatory)

02. Member’s/patient’s details (Name, Member ID, Date of birth etc.)

03. The date of onset of first symptoms

04. Medical Section fully completed (with all information requested therein)

05. Treating doctor’s signature and stamp

06. A copy of the INAYAH Approval email (if any)

07. Any other information requested in the Claim Form

08. A copy of radiology/imaging reports, blood test results, other reports for special/diagnostic procedures etc. (where you have paid and are claiming for radiology/x-rays, imaging procedures e.g. Ultrasound, CT and/or MRI Scans, blood tests, etc.)

09. A copy of the prescription/s (where you have paid and are claiming for medications)

10. Discharge summary and medical report (in case you are claiming inpatient admissions)

11. All invoices (with proper breakdown of amounts) and receipts (clearly showing that cash/credit card payment details made by you)

12. Please note that to process the claim, we require all documents in English. If the claim is in a different language, we will require the translation of the claim to be submitted as well.

11 Why is my Reimbursement amount less than the amount I had claimed for?

INAYAH will reimburse you for the claimed expenses according to coinsurance, deductible, geographical scope and reasonable & customary basis that can be found in your policy provisions. Did you know that if you go within the network of approved medical providers, you will benefit from:
• Direct Payment Facility – Only pay your deductible and Inayah covers the rest
• No claim forms to fill, no documents to collect
• Pre-approvals are arranged by the network medical provider

• Treatment is covered at 100% within the Network You may also have received a lesser amount because you visited a hospital/clinic outside our network of approved providers. We recommend you visit any hospital or clinic in our network.

12 How can I submit an Inquiry or a Complaint?

• Direct Payment Facility – Only pay your deductible and Inayah covers the rest

• No claim forms to fill, no documents to collect

• Pre-approvals are arranged by the network medical provider

13 How can I submit an Inquiry or a Complaint?

Go to Contact Us, Provide the required details and add your Inquiry or Complaint in the “Your Message“ text box and click on “Submit“. INAYAH Customer Service Team will revert within the maximum of 48 hours. You may also email us at contactus@inayahtpa.com

14 What if I have lost my Insurance Card?

Contact your Corporate HR or Insurance Broker immediately if your insurance card is lost.

15 How can I follow up on my reimbursement claim?

You can easily follow up on your reimbursement claim either by emailing to reimbursements@nlicgulf.com or by calling the Call Center number on the back side of your insurance card.

16 How can I find a Hospital, Diagnostic Center, Pharmacy?

You may search for a healthcare provider through the website www.inayahtpa.com or through the Mobile App available on Google Play and Apple Store: Website

• Go to www.inayahtpa.com

• Go to “Healthcare Providers” section

• Go to “Provider Partners”

• Search for a Healthcare Provider by Name, Country, City, Area, Type and Network Mobile App

• Register to NGLIC-Care or Log in through your user name or password

• Go to “Network”

• Search for a Healthcare Provider by Name, Country, City, Area, Type and Network

• You can also locate providers near your home, work or based on your current location.

17 What do I do in an emergency?

Please contact our local Call Center number available at the back side of your insurance card. Our customer executives will provide assistance and clarify procedures.

18 What is a Network Provider?

Network Providers are healthcare facilities (hospitals, clinics, laboratories, pharmacies, etc.) contracted with INAYAH allowing you to benefit from direct settlement of bills only by presenting your insurance card. To see the list of Network Providers you are allowed to use, check your insurance policy or go to Coverage Details on www.inayahtpa.com.

19 How do I arrange direct settlement for planned in-patient treatment?

• Member visits the provider and consults with the physician.

• Provider will submit the request for elective in-patient services via web, email or fax.

• Claim adjudication is done as per policy terms and conditions.

• Provider is replied back with the decision on claim within 48 hours for elective case.

• Provider receives the decision from INAYAH and informs members accordingly to plan the date and timings of service/s to be provided.

20 How can I avail Physiotherapy?

You can avail physiotherapy up to the available number of sessions if referred by your physician on prior authorization basis within the network. If you have reimbursement benefit, you could avail physiotherapy on referral by your physician up to available number of sessions. In this case, you shall have to pay upfront and then apply for reimbursement with all requisite documents mentioned on the reimbursement claim form.

21 What is the Difference between Coinsurance and Deductible?

Coinsurance is a percentage of the service charge that your health plan calculates for you, after you’ve met your deductible. \r\nWhile the deductible is a fixed amount the member pays in each visit or per claim, based on the member’s policy.\r\n

22 What is the Meaning of Abbreviations like Ded, Co-Pay, IP, OP printed on my Insurance Card?

• Deductible (Ded) is the fixed amount which is required to be paid by the member on every outpatient visit.
• Co-payment (co-pay) is percentage of total billed amount which is required to be paid by the member for each in-patient (IP)/out-patient (OP) visit or admission.
• IP stands for In-patient
• OP stands of Out-patient

23 What is the Validity of Medical Pre-Authorizations?

The validity of medical pre-authorizations (approvals) is 07 days. \r\nAfter 07 days, provider is required to contact INAYAH for re-approval.\r\n

24 Do I need to Present any Photographic Identification along with my Health Insurance Card?

Yes. You are required to present your any government issued photographic identity (Emirates ID/passport/driving license) as per local health rules and regulations.

25 What does Waiting period means?

For basic plans there is 6 months waiting period on Pre-Existing and Chronic conditions, which means that for the first six months of the policy client can’t take any treatment pertaining to Pre-Existing and Chronic Problems.

26 What is Pre-Existing and Chronic Conditions?

A pre-existing medical condition is a disease, illness or injury for which you have received medication, advice or treatment for, or experienced symptoms in the five years before availing for the medical insurance policy.\r\n\r\nA chronic condition is a disease or illness that requires long-term treatment to control or manage the symptoms. It may or may not have a known cure and may continue indefinitely and is likely to come back once treated.\r\n

27 Am I covered if I travel away from my area of residence?

This depends on the type of plan you have chosen. For example, if you have selected a GCC coverage then you are also covered in all the other GCC territories. If you have selected Worldwide Cover excluding the USA/Canada then you are covered worldwide except for North America.

28 Are dental services covered?

This depends on the additional cover you choose. If included in your policy it mainly offers routine dental treatment for examinations, compound fillings, extractions and root canal treatment. The number of times these services can be performed and/or the maximum covered amount will be restricted to certain limits as mentioned in the policy terms.

29 What is meant by referral procedure for in-patient and out-patient treatment?

Referral procedure means that you need to first consult a General Practitioner (GP) licensed by the Ministry of Health to cover the consultation of any specialist/consultant doctor in the Policy. The General Practitioner will evaluate if your medical condition needs a specialist’s opinion and accordingly refer you to the specialist or consultant.

30 What if the cost exceeds the level of hospitalization insurance cover?

In such situation, the policy holder will be liable to pay the difference amount. We will inform the hospital about the policy holder’s eligible amount and the hospital will recover the amount over and above the credit amount from the policy holder directly.

31 What is the Outpatient Procedure to be followed for Direct billing/Cashless directly with the Network facility?

Direct Billing/Cashless service can be availed at the network facilities.\r\nThe procedure mentioned below needs to be followed while availing Cashless /Direct Billing.\r\na) Choose network facility from updated network list of hospital on the website.\r\nb) Show TPA ID card and collect Pre-Authorization form from the hospital. Fill up personal details and the rest to be filled up by the hospital treating doctor along with contact number.\r\nc) If the services are upto the authorized limit as per agreement, Network Facility extend the service or else will send request to Inhouse TPA for approval.\r\nd) Inhouse TPA shall process the claim as per policy terms and conditions and send an approval letter to the hospital.\r\ne) Avail the treatment without any payment except for non-payable items as per policy terms. Please ensure claim form is filled and duly signed and final bill is signed before leaving the facility.\r\nf) Payment will be made directly to the Network Facility.\r\n

32 What are the documents required to avail Direct Billing/Cashless facility?

The following documents will be required before issuing cashless Authorization Letter.
a) Duly filled, signed & stamped Pre-Authorization Form from the hospital.
b) Investigation reports & previous consultation papers (if any).
c) Photo ID proof\r\nd) Health ID number/policy number/employee number (Please mention on the INAYAH Claim form and provide a copy of Health ID card).

33 What is Direct Billing Rejection ?

Rejection will be done as per the policy terms and coverage, the below are the few examples for rejection.\r\n\r\na. If hospitalization is for observation & investigation purpose\r\nb. If any particular aliment/disease/treatment is found that are not covered under policy term and condition\r\nc. If found that the treatment can be done under OPD basis\r\nd. If found that no active line of treatment is available\r\ne. If Shortfall and the policy holder has not responded within the given TAT\r\nf. If policy is invalid\r\ng. Rejection of Direct billing is not a denial of treatment\r\n

34 Does Direct Billing/cashless hospitalization mean getting treatment free of cost?

Direct Billing/Cashless hospitalization does not mean that the treatment is free of cost. Any expenses that are not payable under the insurance policy will not be authorized during hospitalization and the same will have to be borne by the patient.

35 Does Direct Billing/cashless hospitalization mean getting treatment free of cost?

36 Does Direct Billing/cashless hospitalization cover all medical expenses?

Charges for telephone, television, barber or beauty services, food charges (other than patient’s diet provided by hospital), baby food, cosmetics, tissue paper, toiletry items, Supplement, Multi Vitamins (only in Deficiency Conditions) and similar incidental expenses are not payable. Policy Exclusions varies from scheme to scheme subject to the terms published in agreed Table of Benefit for each individual policy.

37 What is Claim Rejection?

Refer “What is Direct billing Rejection,” Along with the reasons listed in Direct Billings rejection, the below are the few reasons for claim rejection:
• Claim docs not submitted within the given TAT
• Claim intimation not given
• Date of inception is greater than date of admission
• Fraud/Duplicate Case