Ahly Medical operation procedures:

– Any beneficiary holding AMC’s medical card is entitled to obtain medical services through any medical service provider who is contracted in the medical network as per the operational instructions on the medical card, after assuring the following:

 

A- The identity of the medical card holder through validating the original card.

B-Incase of hospital accommodation the agreed upon hospitals classifications shall be considered as stated on the medical card.

C-The expiration date, covered services, services that need prior approval, copayment, maximum limit for direct service and any other instructions stated on the medical card.

D-In case of medical card absence, a prior approval is issued with a note (without medical card) with the necessity of attaching a copy of the national ID for the beneficiary and assuring its validity.

 

• Copayment to be calculated after applying the agreed upon discount
• If the medical card states that chronic and critical services require approval, please request a prior approval except in the emergency cases services shall be provided directly and approval shall be requested in 1 business day.

 

Critical cases	Chronic cases
Cases that are life threating for the patient if the required medical procedure is not done. Includes:	Cases   that   requires   therapy   more than 3months, and aren’t fully cured. Includes:
1-Heart surgeries 2-Angina 3- Cardiac arrest 4- Catheterization(interventional, exploratory) 5- Multi slice CT the coronary arteries 6-Permanent pacemakers 7-  Renal dialysis 8-Hepatic failure (hospital admission only) 9-Organ transplantations and its follow up 10-Malignant tumors and its complications 11-Unspecified tumors till identifying 12-Stroke/Cerebral Embolism 13-Cerebral embolism 14-Cerebral hemorrhage 15-Mechanical Ventilation	1-Diabetes mellitus 2-Hypertension 3- Glaucoma 4- Chronic renal failure 5-Hepatitis B, C 6- Cardiac myopathy 7- Gastroesophageal reflux 8- Hepatic failure (except hospital admission)

A) Uncovered services:

1- Cosmetic treatment (Cosmetics-moisturizers-Facial whitening cream- Sun protection products)
2- Birth control methods
3- Pre-marital examination.
4- All costs for additional services for hospitalized patients, including but not limited to (telephones, cafeteria, newspaper, magazines, etc.)
5- All tests and treatments of diseases that are caused by immunodeficiency disease (AIDS).
6- The donor costs in cases of organ transplantation
7- All expenses incurred due to treatment in healing centers, hydrothermal resorts, electromagnetic sanatorium and Any similar places even if it is registered under the hospital name
8- Expenses for treatment of diseases and injuries caused by the recruitment or connection of the insured by any military authority whether the injury is a direct or indirect result of any military action, including military training, and wars.
9- Treatment expenses for cosmetic products, alternative medicine, herbal medicine and treatment without consulting a doctor or treatment by an unauthorized physician or family member.

10- The transportation of the insured unless he was transferred by local, licensed ambulance.
11- Vaccination against diseases and pre-employment or pre-travel screening.
12- Sphygmomanometers, Glucose level devices, inhalers, and accessories
13- Preventive treatments and vaccines for Allergy.
14- Solutions for contact lenses.
15- Treatment of genetic baldness, hoariness, baby amenities, and skin bleaching products and unrestrained drugs.

B) Uncovered diagnosis:
1-Obesity
2-Loss of weight
3-Infertility
4-Sexual dysfunction
5-Illegal abortion
6-Circumcision (Male/Female)

7-Diseases and injuries resulting from self-harm:
 Attempted suicide
 exercising dangerous sports
 Fights
 Addiction
 Illegal sexual practices
C) Covered Services that need prior approval:
1-Examinations and treatment of genetic diseases and congenital defects.
2-Immune disease (systemic lupus, rheumatoid arthritis, vitiligo, psoriasis, multiple sclerosis)
3-Consultations, sessions or medicines for the treatment of mental and mental diseases
4-Transplantation and side effects of transplantation
5-Treatment expenses for correcting visual defects
6-All expenses for patients’ companions
7-Vaccinations and preventive medical examinations, medications and drugs

8-Treatment by foreign experts and visitors.
9-The Unpriced drugs by the Egyptian Ministry of Health
10-Hair loss treatment and nutritional supplements
11-Medical supplies and utilities from support for neck, elbow, wrist, knee and ankle
12-The drugs that enhance vitality and activity and prescribed vitamins for a medical necessity to treat cases as (diabetes, anemia… etc.)
13-Hormonal disorders at menopause and compensatory treatments after menopause.
14-Natural disaster injuries and diseases such as epidemics, floods and earthquakes.

1. A) Hospitals, Private clinics and Poly clinics:

Claim Forms:

 

1. A) Required data to be filled in the specified fields on the claim form:

• Personal information.
• All prescribed medications, investigations required with stating the suitable compatible medical diagnosis.
  • The exact service provided with stating the service date.

1. B) One prescription should be issued for each examination service and should not be divided into 2 claim forms.

-Procedures that need prior approval:

1- Any interventional or surgical procedures done in outpatient clinics under general   anesthesia needs prior approval.

2-Endoscopy

3-Audiogram

4-All inpatient and daycare services need prior approval.

5-All dental services provided in hospitals other than examination need prior approval.

6-Anti Natal Care examination and follow up unless otherwise stated on the medical card.

7-OCT and lense optometry

8-All procedures that might require multiple sessions (even if only 1 session needed)

-Procedures that do not need prior approval:

(If not under general anesthesia):

·          Local cast ·          In grown toe nail ·          Removing any foreign bodies from eye or ear ·          Sebaceous cysts ·          Sutures and their removal ·          Ear Wash ·          Abscess drainage ·          Fundus examination & Intraocular pressure ·          Nebulizer sessions ·          Wound dressings ·

• Emergency Services:
• Emergency examination including any specialty calls are counted from the two examinations that the beneficiary can do on the same day.
• Approval should be requested in 1 business day in case the emergency service needed prior approval as stated on the medical card.
• Medical reports should be sent in 1 business day.

 

• Special remarks:

 

• The beneficiary has the privilege to undergo maximum of two consultations per day for two different specialties, further consultations requires prior approval.
• The service should be provided directly through the medical card, with stating the exact procedures done and investigations needed on the assigned claim form.
• The follow up examination is free in seven days from the original service date stated on the claim form unless otherwise specified in the contract.
• Any services that is not stated in the contract, a prior price approval shall be requested.
• In case of claiming for medical supervision or surgeon fees apart from the hospital invoice , the service should be counted as per the agreed upon price list(with the respective doctor) except if the service is not stated in the contract.
• The doctor’s degree shall be clarified in the batch statement otherwise the least fees in the price list to be considered.

B) Special instructions for laboratory services

 

– All laboratory tests may need a prior approval if mentioned on the medical card.

–  All laboratory tests need prior approval in critical and chronic cases if mentioned on         the medical card (as previously mentioned).

– Laboratory tests that need prior approval:

·          All hormones except (T3,T4,FreeT3,FreeT4,TSH) ·          Genetic testings ·          Virology except (HBsAg, HBcAb,HBeAg,HCVAbs,HAVAbs) ·          PCR for any organism ·          Immunity Investigations except (ASO Titer ,CRP , Widal , Brucella) ·          Tumor markers ·          Anti CCP ·          Serum drugs, toxins , antibodies , vitamins ·          Fibro&Acti test ·          Bone Marrow examination ·          Biopsy & Pathology ·          C-Peptide ·          Catecholamine levels

C) Special instructions for radiology services

 

– All radiological services may need a prior approval as mentioned on the medical card.

– All radiological services need a prior approval except:

· Plain X -ray , Barium X-ray, IVP-X-ray · ECG, Stress ECG , ECG Holter · Ultrasound (Abdomen, Pelvic ,Thyroid , Transvaginal , Transrectal) · Multislice and Normal CT scans without contrast (MSCT is counted as normal CT) · All CT scans with contrast (1 ampoule only), further ampoules need a prior approval to be requested. · Spiral CT · Trans-thoracic Echocardiography · All Duplex studies

 

D) Special instructions for medication services

 

• Medication services that need prior approval:
• Medication that exceed the allowable limit if mentioned on the medical card(before calculating discount and copayment), in case of claiming any amounts that exceeds that limit , the claim will be totally deducted even if the beneficiary paid the difference in amounts or requested to decrease the quantity of drugs.
• Medical supports as 🙁 Stockings, orthopedic shoe, back support…)
• All dental medications otherwise stated on medical card.
• All Maternity medications otherwise stated on medical card.
• In case of prescribed medications for duration more than 1 month.
• Drugs that need prior approval:

·         All hormonal therapy except : Thyroxin (local) and Insulin ·         Chemotherapy, drugs for mental and neurological diseases, immunological drugs. ·         Calcium, Calcium supplements, Vitamins, Minerals, All Supplements except (Vitamin B in cases of Diabetes mellitus, Anemia, Neurologic and Orthopedic diseases. ·         Drugs that treat: Acne, Alopecia, Genetic diseases, congenital abnormality, Cases that are not recognized as a disease as: Flat foot. ·         Throat lozenge and mouth wash. ·         Vaginal Douches ·          Local antiseptics

 

• Any alternative drug to be dispensed must contain the same active ingredient and with the same quantity without price exceeding the quantity prescribed.
• In case of not stating the drug concentration the least concentration of the prescribed drug to be dispensed.
• In case of not stating the (quantity / duration of treatment) 1 box of each drug to be dispensed without exceeding dosage of 10 days treatment.
• Intravenous fluids, all medical supplies (syringes, cannulas, gauzes…) are not covered.
• Prescriptions should not be dispensed in bulk.

 

 

1. E) Special instructions for other medical services

-Physiotherapy and Renal dialysis services:

• All physiotherapy and renal dialysis sessions need prior approval.
• If whole physiotherapy sessions is not contracted in the provider’s price list                ,    only maximum 3 modalities to be done per session unless otherwise stated in       the approval.
• Upon submitting the claims the documents for all sessions shall be complete and gathered sequentially in the batch.

 

-Medical glasses services:

• Medical glasses need prior approval(Approval date must be before actual service date)

 

• Prosthetic and hearing aid devices :
• All Prosthetic and hearing aid devices devices need prior approval with stating the type and price of the device on requesting approval, and the local should be dispensed in case of not stating whether the device is local or imported in the approval.

Nice deer approval on any service is considered as a medical approval from Al-Ahly medical company considring all the operation procedures.

• Upon requesting a nice deer approval the following should be considered:

 

1-Claim form serial on the claim form shall be entered in the assigned field, including the English letter such as (H0274775).2-Valdiating the provider name stamped on the claim form with the provider name on Nice deer3-Choosing the examination date stated on the claim form 4- Choosing the service type according to the stated medical diagnosis(Acute-Chronic-Maternity-Dental)

 

• On dispensing the monthly medication, the beneficiary’s card number is entered in the card number field, the claim form and the prescription are attached to nice deer receipt unless otherwise stated in the notes field.

Documents required to claim the provided services through nice deer:

1-Cover letter stamped with original stamp and is generated from nice deer online system.

2-Detailed statement, stamped and signed and is generated from nice deer online system, also, another soft copy to be sent (Excel sheet) on E-mails:  (Provider.support@ahlymedical.com) and (Claims.archiving@ahlymedical.com

3-Detailed receipt for every provided service stamped with the provider’s stamp.

4-Nicedeer’s receipt/approval stamped with the pharmacy’s stamp.

5-The claimed receipts are to be arranged according to the statement’s arrangement.

6-The original request and the allotted claim form must be attached to the receipt unless otherwise stated in the notes.

 

• The claimed service provided through nice deer to be presented to AMC in a separate batch other than batches presented through providing offline services on a monthly basis to facilitate the medical auditing.

 

• The claim form serial stated on the claim form should be revised carefully, and assuring that it is placed in the assigned field.
• The claim form serial on the claim form shall be validated with the mentioned one on the prior approval issued.
• On requesting approval through nice deer, the claim form serial should be validated with the one on the claim form.
• In Case of any variation in the previously mentioned instructions, please contact the customer service numbers placed on the back of medical card.

 

-Please make sure of attaching all the following documents on submitting any batches consedring Al Ahly medical company’s operation procedure:

1. A) Cover letter stamped with provider’s original stamp.
2. B) Detailed batch statement signed and stamped by the provider, also a soft copy (excel sheet) to be sent on E-mails :(support@ahlymedical.com) and (Claims.archiving@ahlymedical.com)
3. C) EDI with the following data:

Net Amount after dicount and copayement

Copayement percentage

Total after discount

Total before discount and copayement

Service type

Service date

Card number

Beneficiary’s name

#

 

• Medical diagnosis-beneficiary’s name, beneficiary’s card number, date of examination, beneficiary’s signature, and provider’s stamp) should be clear on the claim form.
• In case of claiming inpatient hospital services that should be mentioned in the final cover letter.
• Any medical service that need a prior approval as per operation procedure, the prior approval should be attached in the batch or the phone approval ID.

Documents required to claim provided services

Service Name	Claim Form	Procedures	Other documents	Approval
Consultation	White	√		As stated on medical card
Radiology	Red	√		As stated on medical card
Laboratory	Yellow	√		As stated on medical card
Medication	Blue	√	Detailed bill	As stated on medical card
Outpatient services	Green	√		As stated on medical card
Physiotherapy sessions	Green	√	Follow up card (Patient’s name, signature, dates and number of sessions, modalities.)	Ö
Renal dialysis sessions	Green	√	Follow up card (Patient’s name, signature, dates and numberof sessions, modalities.)	Ö
Optics services	Green	√	Optometry detection report+detailed bill	Ö
Prosthetic and hearing aid devices	Green	√	Detailed bill	Ö
Physician fees in private clinics		√	Medical report	Ö
Inpatient services		√	Medical report+Detailed bill	Ö
Internal catheters		√	Medical report+Detailed bill+CD+Sticker	Ö

(Beneficiary’s name and signature-Service date –Number of sessions-Provider’s stamp) shall be stated on the follow up card.

• The approval date must be before the service date, noting that the validity of the approval is 7 days and the validity of the claim form is 15 days.
• On requesting approval, the approval must include all the mentioned procedures in the request.
• A clear medical diagnosis should be present on the claim form upon providing any service to AMC’s beneficiaries.
• In case of the inability to have a copy of the prior approval issued for the service , approval number to be requested from the approval department as a phone approval through the telephone numbers stated on the the back of the medical card.
• In case of any modification, elimination, cancelation on the approval’s stamp, please contact the customer service numbers placed on the back of the medical card.
• A price approval must be requested, if the service to be provided is not contracted.
• In case of any modifications or addition on the claim form, the original stamp of the provider must be present.
• In case of hospital claims, please specify number of inpatient and outpatient claims separately on the cover letter.
• In case of any modifications on the claimform or the bills another stamp next to the modification shall be present.
• Incase of any objections regarding the deductions, please contact AMC in maximum of 15 days of receiving the cheque though sending an email to: resubmission@ahlymedical.com clarifying all the details related to the claims.

• For any inquiries , Please contact us on:
• For medical network inquiries:
• Phone: 02-33340555(From 8 AM till 10 PM during business days)
• Email: provider.support@ahlymedical.com
• Website: www.ahlymedical.com

 

• For beneficiaries –related inquiries:
• Phone: On the back of the medical card.