chi_gov_sa · form · processed · 4 chunks
شمان
مجلس الفيمان الصحي
Council of Health Insurance
ملحق رقم (1)
نموذج طلب المواقفات والمطالبات الموحد
UCAF
شمان
مجلس الضمان الصحي
Council of Health Insurance
Appendix no. (1): UCAF
<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 unified 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 الاليحه التنفيذيه لنظام الضمان الصحي التعاوني لمعابير 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 بمعابير الترميز المعتمده من المجلس. وان تكون الخدمات حسب قوايم الاسعار المتفق عليها حسب النموذج رقم (٥). هذا النموذج يجب ان يكون جزء من متطلبات المطلابه التي ترسل من قبل المرفق الصحي الي شركه التامين.</td></tr></table>
UCAF 2.0
To be completed & ID verified by the reception/nurse:
Provider Name: ....
Insurance Company Name: ....TPA Company Name: ....
Patient File Number: .... Dept.: ....
Single ( ) Married ( ) Plan Type ( )
Data of visit / /
New visit ( ) I Follow Up ( ) I Refill ( ) I walk in ( ) I Referral ( )
Print/Fill in clear letters or Emboss Card:
Insured Name: ....
ID. Card No. ____ Sex ____ Age ____
Policy Holder ...... Policy No ......
Expiry Data / /
Approval ....
To be completed & by the Attending PHYSICAIN: Please tick ( √ )
Inpatient ( ) Outpatient ( ) Emergency Case ( ) I Emergency Care Level: 1 ( ) 2 ( ) 3 ( )
BP:....../.... Pulse:....bpm Temp ....C Weight:....Kg Height:....cm R.R:.... Duration of Illness:....(Days)
Chief Complaints and Main symptoms....
Significant Signs: ....
Other Conditions ....
Diagnosis....
Principal Code: 2 \( ^{nd} \) Code: 3 \( ^{rd} \) Code: 4 \( ^{th} \) Code:
Please tick ( √ ) where appropriate:
Chronic ( ) Congenital ( ) RTA ( ) Work Related ( ) Vaccination ( ) Check-Up ( )
Psychiatric ( ) Infertility ( ) Pregnancy ( )
Suggestive line(s) of management: Kindly, enumerate the recommended investigations, and/or procedures For outpatient approvals only:
<table><tr><td>Code</td><td>Description/Service</td><td>Type</td><td>Quantity</td><td>Cost</td></tr><tr><td></td><td></td><td></td><td></td><td></td></tr></table>
Providers Approval/Coding Staff must review/code the recommended service(s) and allocate cost and complete the following:
Completed/Coded BY
Signature
Data /
<table><tr><td>Medication Name (Generic Name)</td><td>Type</td><td>Quantity</td></tr><tr><td></td><td></td><td></td></tr></table>
I Case management Form (CMF 1.0) included
Yes ( )
No ( )
Please specify possible line of management when applicable:
Estimated Length of stay
days
Expected date of admissions: / /
I hereby certify that ALL information mentioned are correct and that the medical services shown on this form were medically indicated and necessary for the management of this case.
Physician
Signature
Stamp
Date
/ /
I hereby certify that ALL statements and information provided concerning patient 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:
Days
Comments (include approved days/services if different from the requested)
Approved/Disapproved by
Signature
Data
/ /
(*)This is applicable only in case of manual UCAF