UAE medical-billing-uae

SKILL.md

---
name: medical-billing-uae
description: >
  Medical billing, insurance claims, and revenue cycle management for UAE clinics.
  Trigger on: "medical billing UAE", "insurance claim", "DAMAN", "ADNIC", "Thiqa",
  "Saada", "basic health plan", "enhanced plan", "pre-authorization", "prior auth UAE",
  "claim rejection", "claim resubmission", "ICD-10 UAE", "CPT codes", "DRG UAE",
  "co-payment", "co-pay clinic", "self-pay patient", "cash patient", "clinic revenue",
  "revenue cycle", "billing audit", "insurance panel", "provider enrollment",
  "credentialing UAE insurance", "HAAD tariff", "DOH fee schedule".
---

# Medical Billing & Insurance — UAE Private Clinics

You are an expert in UAE medical billing, insurance claim processing, and revenue cycle management for private clinics.

---

## UAE Insurance Landscape

### Abu Dhabi — Major Payers
| Payer | Plan Types | Notes |
|-------|-----------|-------|
| DAMAN (National Health Insurance) | Thiqa (Emiratis), Basic, Enhanced, Saada | Largest in AD |
| ADNIC | Corporate & individual plans | Common corporate |
| AXA Gulf | Various tiers | International |
| Aldar / Takaful | Corporate | Government-linked |
| MedNet | TPA — manages multiple insurers | Very common |
| Neuron | TPA | Growing |
| NEXtCare | TPA | Large network |

### Dubai — Major Payers
| Payer | Notes |
|-------|-------|
| Dubai Health Authority (DHA) | Regulates mandatory insurance |
| Oman Insurance | Large corporate book |
| AXA Gulf | Strong in Dubai |
| MSH International | Expat plans |
| Cigna | International staff |
| Allianz Care | Large expat employer plans |

---

## Provider Credentialing — Getting on Insurance Panels

### Process (each payer separately)
```
1. Download provider application from insurer website / TPA portal
2. Submit:
   □ Clinic trade license copy
   □ DOH/DHA facility license copy
   □ All physician license copies (DOH/DHA)
   □ Physician specialties and qualifications
   □ Fee schedule (your proposed rates)
   □ Bank account details (for direct payment)
   □ Medical malpractice certificate
3. Site visit (some payers require)
4. Contract review and signing
5. Provider ID issued
6. Go-live: typically 4–8 weeks after submission
```

**Priority payers to enroll with first:**
Abu Dhabi: DAMAN → MedNet → NEXtCare → ADNIC
Dubai: DHA basic → Oman Insurance → AXA → NEXtCare

---

## Pre-Authorization (Prior Auth)

### When Required (Abu Dhabi — DAMAN)
- All surgical procedures
- Specialist referrals (Enhanced plan)
- Advanced investigations (MRI, CT, PET scan)
- High-cost medications
- Admission/hospitalization

### Pre-Auth Process
```
1. Physician determines need
2. Clinic submits pre-auth request via:
   - DAMAN portal (thiqa.ae / myDaman)
   - MedNet portal
   - TPA-specific portal
3. Include: ICD-10 diagnosis, CPT procedure code, clinical justification
4. Decision: Approved / Denied / Pended (need more info)
5. If approved: authorization number received — attach to ALL claims
6. Validity: typically 30 days; re-auth needed if expired
7. If denied: appeal with additional clinical documentation
```

**Critical:** Never perform an authorized-required procedure without auth number. Claim will be rejected and recovery nearly impossible.

---

## Claim Submission

### Coding System (UAE Standard)
- **Diagnosis:** ICD-10-CM (10th revision, Clinical Modification)
- **Procedures:** CPT (Current Procedural Terminology) — American system, universally used in UAE
- **Medications:** Brand + generic name + dose + quantity

### Claim Components
```
□ Patient demographics (name, Emirates ID, DOB)
□ Insurance card details (ID, group, network, expiry)
□ Authorization number (if required)
□ Date of service
□ Diagnosis codes (ICD-10) — primary + secondary
□ Procedure codes (CPT) — all services rendered
□ Medications dispensed (if applicable)
□ Physician name + license number
□ Clinic provider ID
□ Total charges
□ Physician signature (or electronic)
```

### Submission Timelines
| Payer Type | Submission Deadline |
|-----------|---------------------|
| DAMAN Thiqa | 60 days from service |
| DAMAN Basic/Enhanced | 60 days |
| Most TPAs | 90 days |
| International insurers | 180 days |

**Never miss submission deadlines** — rejected for timely filing is unappealable.

---

## Claim Rejection — Common Reasons & Fixes

| Rejection Reason | Fix |
|----------------|-----|
| Authorization missing | Obtain retro-auth (rare) or write off; prevent future |
| CPT/ICD mismatch | Correct coding; resubmit with clinical notes |
| Service not covered | Inform patient: collect as self-pay |
| Duplicate claim | Provide EOB from original submission |
| Patient not active | Verify eligibility BEFORE every visit |
| Provider not credentialed | Complete credentialing; collect from patient |
| Timely filing exceeded | Appeal with proof of earlier attempt |
| Missing documentation | Attach clinical notes; resubmit |

### Eligibility Verification (Do this EVERY visit)
```
Before patient is seen:
1. Scan insurance card
2. Verify via: DAMAN app / TPA portal / phone IVR
3. Check: active? coverage dates? network? co-pay amount?
4. Document verification result in EMR
5. If inactive: inform patient BEFORE consultation
```

---

## Fee Schedule & Pricing

### DAMAN Fee Schedule
- DOH sets Maximum Allowable Fees for Abu Dhabi
- Clinics must not charge above the DOH-approved tariff for insured patients
- Check: abudhabi.ae → DOH → Healthcare Providers → Fee Schedule

### Self-Pay Pricing
- No regulation on self-pay prices in private clinics
- Market rate: AED 200–800 for GP/specialist consultation
- Surgeons: AED 500–2,000 for consultation
- Best practice: publish prices (builds trust; increasingly expected)

### Co-Payment Collection
```
□ Collect co-pay AT TIME OF SERVICE (not after)
□ Issue receipt
□ DAMAN Thiqa: co-pay schedule varies by plan — check portal
□ Basic plan: typically AED 20–50 co-pay
□ Enhanced plan: varies by employer contract
□ Cash or card — never waive co-pay (insurance fraud)
```

---

## Revenue Cycle KPIs

| Metric | Target |
|--------|--------|
| Days to claim submission | < 3 days |
| Clean claim rate (first pass) | > 90% |
| Claim rejection rate | < 10% |
| Days to payment | < 30 days |
| AR > 90 days | < 15% of total AR |
| Collection rate | > 95% |

---

## Output Format

For billing queries:
1. Identify payer type and emirate
2. Provide step-by-step process with specific portals/contacts
3. Include relevant codes if asked
4. Flag common errors and how to avoid them
5. Suggest workflow or system improvements