KSA Health Insurance: New Claims Process Becomes Effective in October 2018
Update by: Wayne Jones, Saud Alsaab and Sara Al-Hudaithy
The Council of Cooperative Health Insurance (CCHI) issued a circular on 22 July 2018 addressed to all health insurers, healthcare providers and TPAs that a new claims settlement process will come into effect in October 2018. Below we provide a short summary of the new process.
The CCHI requires the claims process to include the following:
- Healthcare providers (i.e. hospitals) to file the claim directly to the insurance company or through a TPA within 45 days from the date of the entitlement of the claim;
- Insurers shall settle the completed and approved claims within 45 days from the date of receiving the claim. In relation to claims that have been rejected by an insurer, the insurer shall provide the service provider with a list of the rejected claims with all necessary reasons/justification;
- In case the rejected claims are due to lack of information or supporting documents, the healthcare providers shall review the rejected claims and provide the insurance company with any supporting documents and answers within 22 days from the date of receiving the rejected claims list; and
- The insurance company shall review the documents received from healthcare provides, and if approved, settle the claims mentioned in (3) within 22 days from the date of receiving the comments on the outstanding claims.
Furthermore, the circular provided that the CCHI will supervise the financial settlements between the insurance companies and service providers on semi-annual basis.
The CCHI stated that in circumstances where the insurance company and the TPA have not agreed on the final settlement, or in case of any delays, the case will be referred to the settlement centre in the CCHI.
Whilst the 45 days delays of submitting and processing the claim by insurers and healthcare providers are mentioned in the Implementing Regulations of the Cooperative Health Insurance Law. However, the rejected claims process is new and was not previously addressed by the law or the implementing regulations.
Insurers, TPAs and healthcare providers are advised to take all necessary steps to furnish their claims handling process with the required timelines before October 2018. Failure to comply with CCHI regulations, circulars and instructions is considered a violation of Cooperative Health Insurance Law and its implementing regulations, and can result in financial penalties as well as suspension/cancellation of the accreditation of health insurance companies and TPAs.
