Claims Management

Case Description

Customers may reach out to inquire about or process a new claim, or to follow up on an existing claim. This SOP outlines the steps to assist customers with their claims-related inquiries.

Resolution Steps

1. Generic Statement:

   • Begin by disclosing the following statement to the customer:
     “We’re happy to help you with answers to your questions. However, there are always variations from one patient to another, and coverage can differ from one case to another. For accurate information regarding your policy or an active claim, we advise you to contact [Relevant TPA Name].”

2. Capture Sponsor’s EID Number:

   • Ask the customer to provide their Sponsor’s EID Number.

3. Access Admin Portal:

   • Navigate to Admin Portal > Reports > Purchased Policies Report.

   • Look up the customer’s policy using the EID number and inspect the results.

4. Evaluate the Case:

   • If the customer is insured and has a general inquiry about policy benefits and coverage:

     • Provide the necessary information based on the policy details.

   • If the customer is insured and wants to take action related to a healthcare provider, process a claim, or follow up on a case:

     • Refer the customer to contact the Relevant TPA directly.

     • Alternatively, guide the customer to check the status of a pre-existing claim/approval on the TPA app (if applicable).

5. Provide TPA Contact Information:

   • Share the relevant TPA’s contact details with the customer:

     • Mednet: 800 MEDNET

     • NextCare: +971 4 270 8800

6. Document the Case:

   • Log the customer’s inquiry and actions taken in the CRM system for future reference.

General Verbiage

• “I understand your concern. Let me check your policy details to assist you further.”

• “For specific details about your claim or policy, I recommend contacting the relevant TPA directly. Here’s their contact information: [TPA Phone Number].”

Conclusion

This SOP ensures a structured approach to handling customer inquiries related to claims. It provides clear steps to verify policy details, guide customers to the appropriate TPA, and document the case for future reference.