eauthorization on Helping Patients Get The Services they Need Faster 8 th December 2016 DHA, Health Funding Department

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1 eauthorization on Helping Patients Get The Services they Need Faster 8 th December 2016 DHA, Health Funding Department 0

2 Overview Mihtab Mohamed El Mubarak Health Economic Analyst 1

3 Role of the Health Funding Department Implementation of the Dubai Health insurance Law 11 of 2013 Implementation of Insurance System for Advancing Healthcare in Dubai (ISAHD). ISAHD is a comprehensive initiative of the Dubai Health Authority (DHA) intended to provide sustainable high quality healthcare in Dubai for nationals, residents and visitors. Regulation of the Dubai private insurance sector We regulate both Payer and Provider behavior and compliance to the Dubai Health insurance Law 11 of

4 eauthorization on eclaimlink DHA s Health Funding Department, introduced eclaimlink in 2012 as an all-in-one electronic hub that manages health transactions with its medical, financial and administrative information with superior efficiency. While also offering a faster, smarter and more efficient pathway to the DHA s strategic goals, and to strengthen Dubai s role as a world-class health regulator and provider. Today, Dubai Health Authority s Health Funding Department is pleased to announce the launch of The eauthorization Initiative on eclaimlink 3

5 What is an Authorization? A decision made by a Payer that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary and is covered by the policy or plan. Sometimes called prior authorization, prior approval or precertification. Current state Manual request/authorization and follow up by phone, or fax. variability in payer prior authorization forms and processes unified or standard template for requests Difficult to automate 4

6 Current Situation Vs eauthorization Future state with eauthorization Unified standard request fields submitted electronically Unified guidelines, which will be updated with market input Efficient pathway connecting ALL Payers and Providers Response time monitoring and standard benchmarking Real time eligibility check that will determine whether a patients plan or policy is active and whether it is accepted at a particular facility or not. Once fully implemented we believe the eauthorization system can benefit all player in the healthcare system by dramatically reducing administrative costs and burdens, improving efficiency and ultimately ensuring patients receive the services they need, faster. 5

7 The eauthorization Cycle Based on the Agreement between the Payers and Providers Healthcare Provider Prior Request 1 Health Insurance Company or TPA Claim Submission 3 2 Prior Authorization 4 Remittance Advice DHPO 6

8 Regulation Ali Fareed Lutfi Head of Payer Regulation 7

9 What is required of Payers and Providers? eauthorization will be mandated for use by ALL Providers and Payers on 1st January 2017 Both Providers and Payers are required to integrate to DHPO, if they have an EMR system or be ready to use the free, online tool on eclaimlink Although the Dubai Health Insurance Law 11 of 2013 primarily focuses on Dubai Policy Holders, the eclaimlink system has been designed as a communication pathway to accommodate for all policy holders regardless of origin and all Providers regardless of their emirate of their Origin 8

10 Regulatory Guidelines Emergency Activities Emergency activities do not require prior authorizations until stabilization, with justification. Definition of Emergency per Dubai Health Insurance Law No 11 of 2013 The Dubai Health Insurance Law No. 11 of 2013 (The Law ) defines an Emergency as the case which requires immediate medical attention by a health services provider for the rescuing of a person s life or the elimination of the hazard threatening such person. This is understood to include services that eliminate the threat of loss of limb or function. Full guidelines can be found on this link: 9

11 Regulatory Guidelines Review Guidelines and policies will be reviewed quarterly with input from the Stakeholders Consultations and Inputs Group (SCIG), this group was formed and includes a representative from all Hospitals and Groups and also some Clinics and centers. Input from Payers s will also be incorporated so members of various working parties will be invited to participate in these quarterly feedback sessions. Feedback will be documented and shared on eclaimlink. 10

12 What Will Health Funding Department Monitor? Type of services provided vs. provider type Type of services provided vs. clinician specialty Payer response times will be accessed and reported Quarterly Adherence to the published eauthorization guidelines 11

13 Demonstration Peaches Conception Dimensions Healthcare 12

14 Q&A For further communication related to this topic: Regulatory: Data: Technical: Training: 13