Medical Billing & Insurance — UAE Private Clinics

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UAE Insurance Landscape

Abu Dhabi — Major Payers

Dubai — Major Payers

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

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

Claim Rejection — Common Reasons & Fixes

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

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