Optical Claims Approval Form (OCAF)

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document_type=form entity=format:application/pdf entity=language:en language=mixed taxonomy_l1=economy_finance taxonomy_l2=insurance taxonomy_l3=health_insurance validity=valid validity_confidence=0.6
شمان
مجلس الفيمان الصحي
Council of Health Insurance
ملحق رقم (3)
نموذج طلب المواقفات والمطالبات لخدمات
العيون
OCAF

صمان
مجلس الضمان الصحي
Council of Health Insurance
Appendix no. (3): OCAF
<table><tr><td>Referring to Appendix No. (2) of the executive regulations of CCHI for the criteria of requesting approval to bear the costs of treatment, which clarified the procedures followed in the event that approval is requested by healthcare providers and the responsibilities of insurance companies to comply with what is stated therein. The Optical form must include all the basic information mentioned in it, the coding standards approved by the council must be adhered, and the services must be according to the price lists agreed upon according to form No. (6) in this contract. This form should be part of the claim requirements that are sent by the healthcare providers to the insurance company.</td><td>اشاره الي الملحق رقم (2) من اللايحه التنفيذيه لنظام الضمان الصحي التعاوني لمعايير طلب الموافقه علي تحمل تكاليف العلاج، التي اوضحت الاجراءات المتبعه في حال طلب الموافقه من قبل المرافق الصحيه ومسيолиيات شركات التامين للالتزام بما ورد فيها. النموذج الموحد يجب ان يتضمن جميع المعلومات الاساسيه المذكوره فيه وان يتم الالتزام بمعايير الترميز المعتمده من المجلس وان تكون الخدمات حسب قوايم الاسعار المتفق عليها حسب النموذج رقم (6). هذا النموذج يجب ان يكون جزء من متطلبات المطلابه التي ترسل من قبل المرفق الصحي الي شركه التامين.</td></tr></table>

OCAF 2.0
To be completed by the reception/nurse:
Provider Name:
Insurance Company Name:
TPA Company Name:
Patient File Number:
Data of visit / /
Plan Type ( )
New visit ( )
I Follow Up ( )
Print/Fill in letters or Emboss Card:
Insured Name:
ID. Card No.
Sex
Age
Policy Holder
Policy No
Expiry Data / /
Class
Approval
To be completed by the Optician:
<table><tr><td colspan="7">RIGHT EYE</td></tr><tr><td>Sphere</td><td>Cylinder</td><td>Axis</td><td>Prism</td><td>V/N</td><td></td><td></td></tr><tr><td>Distance</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Near</td><td></td><td></td><td></td><td></td><td></td><td></td></tr></table>
<table><tr><td colspan="5">LEFT EYE</td></tr><tr><td>Sphere</td><td>Cylinder</td><td>Axis</td><td>Prism</td><td>V/N PD</td></tr><tr><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td></tr></table>
<table><tr><td>Bifocal</td><td>Add</td></tr></table>
<table><tr><td>Vertex</td><td>Add</td></tr></table>
<table><tr><td>Bifocal</td><td>Add</td></tr></table>
Regular Lenses Type:
□ Glass
□ plastic
none
Lenses Specification:
□ Multi – coated
Medium
Anti-reflecting coating
□ Varlux
Lenticular
Photosensitive
□ Light
□ Single Vision
□ High Index
□ Aspheric
□ Dark
Colored
□ Bifocal
□ Safety Thickness
□ Anti - Scratch
Contact Lenses Type:
□ Permanent
□ Disposal
Frames:
□ Yes
□ No
Please specify # of pairs:......
Estimated Cost:
Leases: SR. ....
Frame: SR. ....
I hereby certify that All information mentioned are correct and that the services shown on this form were medically indicated and necessary for of this case.
Optician Signature & Stamp
Data / /
I hereby certify that All statements and information provided concerning patient identification and the present illness or injury are TRUE.
Name and relationship (if guardian):
Signature (*)
Data
/ /
For Insurance Company Use Only: Approved ( ) Not Approved ( )
Approval No:
Approval Validity:
Comments (include approved days/services if different from the requested)
Approved/Disapproved by
Signature
Data
/ /
[Non-Text]