Obs Gyn - Workshop Final

Welcome to Daman
SEHA_DAMAN Denial Workshop

Obstetrics and Gynecology
17/03/2016
Welcome to Daman!
Speakers
Hamad AlMehyas,
Chief Process Officer
Suhad Al Kilani,
Senior Supervisor, Claims Department
Rasha Mostafa,
Manager, Medical Standards & Research
Doudle Carmela Magcalas,

Senior Officer, Medical Standards & Research
23/03/2016 SEHA Workshop 2

Presentation Contents
1. Speakers Introduction
2. DAMAN Overview
3. Claims Process Cycle
4. Medical Necessity Review in DAMAN
5. SEHA_DAMAN Denial Discussions
6. Closing Remarks

Daman Overview
Daman Background
Mandatory Health Insurance Law
The Health Insurance Law for Abu Dhabi was issued on 10th September 2005 with the
following objectives:
Access to Quality of Reduction of

Healthcare Healthcare Subsidies
Ensure affordable Improve the quality Gradually reduce
access to essential of healthcare the need for
health care for all across the Emirate government
people living and of Abu Dhabi by subsidies over the
President H. H. Sheikh Khalifa working in the providing a fair and coming years
Bin Zayed Al Nahyan Emirate of Abu reliable funding
has issued Law No. 23 - 2005 Dhabi system
making it compulsory for
employers and business owners
in Abu Dhabi to provide health
insurance coverage for their
expatriate employees and their
families.

Daman Background
Timeline Setup
Preparation & Setup Phase 2 Rollout

Feb - Aug 2005 1st January 2007
Selection of November 2005 Health insurance
international Start of project in compulsory for all
partner (tender): Abu Dhabi. Expatriates.
several 950,000 Daman
international December 2005 insured members
companies Signing of end 2007.
approached. contracts
between Daman
and Munich Re.
2005 2006 2007 2008
1st May 2006 1st July 2006 June 2008

Start pilot All Expatriates of Compulsory health
phase government and insurance for UAE
companies with nationals.
1,000 employees. Risk carrier
Around 250,000 Government.
Daman insured Daman Management
Phase 1 Rollout members end TPA.
2006. Phase 3 Thiqa Programme

Daman Background
Shareholding and Regulation
Daman falls under the supervision of different regulators.
HAAD Regulator
Insurance Authority for Health Insurance
Regulator
For Insurance Dubai Health Authority
for Health Insurance
Management
Reinsurer 250 million AED Agreement
Munich Re Capitalization Munich Health
Strategic Partner & Reinsurer Daman Holding**

Daman Overview
Statistical Overview
2.8 24
million million
members received
claims
annually
590,000 1,600+
managed calls employees,
annually from 50+
nationalities

Daman Overview
Daman Organizational Workflow

Damans Lines of Business
Insurance Plans and Thiqa Programme
Basic Enhanced Portfolio Thiqa
For Expatriates residing in Products with different For all UAE Nationals.
the Emirate of Abu Dhabi benefits: Core, Enhanced Daman is the exclusive
with a monthly total salary and Care. Third Party Administrator
package less than 5,000 Risk-based pricing (TPA) for the Thiqa plan.
AED per month. (individual and group Risk Carrier: Abu Dhabi
Subsidized, standard policies). Government.
policy of 600 AED p.a.

Claims Process Cycle
E-Claims Overview
1 - eClaim Submission
2 - XML Remittance Advice
Shafafiya
Provider submits
Submission
eClaim through
Shafafiya.
Daman replies
with 1st RA
(cheque).
Provider submits Provider
eClaim 3 - eClaim Resubmission
Resubmission.
Daman replies
with the 2nd RA
(cheque) 4 - XML Remittance Advice

E-Claims Overview
Electronic claims received from Healthcare Providers are processed and paid within 45 days for Thiqa and
Enhanced and within 30 Days for Basic

E-Claims Overview
The received claims are processed either automatically or manually; this is determined based on
certain criteria.
Received Claims
Manual Automatic
Processing Processing

Claims Received Data
Daman receives the information provided by the providers electronically as E-Claims; Diagnosis and
Medical Services are represented by codes (such as ICD9-CM, CPT, etc.). The claim also contains
extra data as listed below:
Patient Details
Policy Number
Provider information
Claims ID
Received Date
Prescription Date
Claims Data Batch number
1ry source is
Member Services Performed Codes (e.g. Labs, Procedures, Medications)
Insurance Card
Diagnosis Codes
#
Quantity Claimed
Claimed Amount
Observation Notes
Authorization Number
Clinician ID

Processing Criteria
Claims judgment is based on the below criteria:
Member Eligibility
Member Age and Gender
Provider Network Eligibility
Coverage and Exclusions of Insurance benefits
Processing
Authorization (pre-approval) Requirement
Criteria
Contracts and Prices
Coding and Billing Rules
Clinicians Specialty
Medical Necessity and Published Guidelines

Sample Claim
A sample of the data received on a Claim:

Medical Necessity Review in DAMAN
Medical necessity is the last stage in the Claims process review
Once a Claim Passes all the previously highlighted checks, it will be

reviewed for medical necessity. Failure at any stage will cause the claims
being sent back to the provider with the corresponding Denial Code.
None of the physician EMR notes are transferred on E-claim sent to

DAMAN during first submission.
Claim Adjudication is based on the data received in the form of codes for
both the Diagnosis and Services performed.
Judgment is based on the one to one co-relation between the submitted

Diagnoses and services.
Whether in the Human or Automated review, best practice evidence is used

as a basis for the decision as much as humanly possible.

If a claim is denied for a justified service there are several ways to rectify it
In the event a Denial for a service is received from DAMAN which is justified,
there are means to Rectify:
2 resubmission attempts : 2000 character description allowed per service

denied.
Arbitration channels - emails to:
SEHAclaimsqueries <SEHAclaimsqueries@damanhealth.ae>
MSRQueries <MSRqueries@damanhealth.ae>
Meetings with Daman providing best practice evidence ( such as this

forum)

Key MessageDisclaimer
At the time of adjudicating the claims, our decisions regarding the

appropriateness of the services will depend upon the specific content of the
coding submitted along with the claim. These decisions reflect payment rules
and are not to be construed as medical advice.
This workshop is all about how you can contribute to better comprehension of
your claims.

As an Expert Physician there is a lot you can do to contribute
Prior to finalizing your EMR documentation, kindly ask yourself one question:
Will the Diagnosis Codes justify

each and every service ordered ?

Diagnosis Code Claimed Diagnosis Description

Quantity
651.03 - Twin pregnancy, antepartum
V91.03 - Twin gestation, dichorionic/diamniotic
Case
Lab Procedure Lab Procedure Description
Code
76811 2 Ultrasound, pregnant uterus, real time with image
documentation, fetal and maternal evaluation plus
detailed fetal anatomic examination, trans
abdominal approach; single or first gestation
Looking at the sample Claim provided above, what would you predict would
be Damans Review result ?

Diagnosis Code Claimed Diagnosis Description Daman Review

Quantity
V91.03 - Twin gestation, NA
dichorionic/diamniotic
Case Lab Procedure Code Lab Procedure Description
76811 2 Ultrasound, pregnant uterus, real Pay 1
time with image documentation, Quantity and
fetal and maternal evaluation plus Second will be
detailed fetal anatomic examination, denied with
trans abdominal approach; single or X MNEC-005*
first gestation
What Diagnosis code/s was missing and would have secured a 100% payment
for all the services?
* MNEC-005: Service/supply may be appropriate, but too frequent

23/03/2016 SEHA Workshop * MNEC-004: Service not clinically indicated based on good clinical 24
practice, without additional supporting diagnoses/activities
Diagnosis Claimed Diagnosis Description Daman Review

Code Quantity
NA
V91.03 - Twin gestation, dichorionic/diamniotic
Procedure Lab Procedure Description
Code
Case
detailed fetal anatomic examination,
transabdominal approach; each additional
gestation
Now the claim is fully payable!

SEHA_DAMAN Denial Discussions
How was it set up?
Task Force from SEHA and DAMAN was Daman team reviewed a
set up September 2015 sample of the data ( aim is 80%
Top 10 specialties with Denials were of denied amounts)
selected ONLY Medical Necessity
denials were reviewed
Data is for 2015 Claims DAMAN
Rheumatology was 1st pilot Other denial reasons are
for high specialization/cost Initiative Data addressed in a separate
workshop
Set up Analysis
Denial Review
Denial
Workshop at DAMAN HQ to Workshop Speciality Obs/Gyn Specialty POC Dr
present findings and other Physicians Point of Teodora reviewed and provided
relevant information to the SEHA expert feedback to further clarify
Physicians Contact some denials
Obtain Feedback on the Sent back to Daman for
relevance/success of the workshop review and re-alignment
Agreed claims are ready to be
settled through Resubmission
Tips for Diagnosis Coding
As per Coding rules, in the outpatient setting a diagnosis SHOULD NOT be

coded unless definitive.
Some coding rules for the obstetric setting:
Do not Code V22.0 (Supervision of normal first pregnancy), V22.1 ( Supervision

of other normal pregnancy) together with Chapter 11 ( complication of
pregnancy, childbirth and the puerperium (630-679) in the same claim
Do not Code V22.0 (Supervision of normal first pregnancy), V22.1 ( Supervision
of other normal pregnancy) together with V23.xx (Supervision of High risk
pregnancy) in the same claim
Use additional codes from other chapters in addition to Chapter 11, to identify
the conditions as appropriate.
E.g. 648.83 Abnormal glucose tolerance should have additional code from Abnormal
Glucose series 790.21 790.29)
Do not Code antepartum condition plus a delivered or postpartum condition
in the same claim

Antenatal tests breakdown as from the HAAD antenatal standard

Antenatal tests breakdown as from the HAAD antenatal standard

Fetal non-stress test ( CPT 59025) indications
Known Indications:
Diabetes Pre-gestational diabetes, gestational diabetes treated with anti-hyperglycemic drugs, or gestational diabetes poorly controlled with nutritional
therapy alone.
Hypertensive disorders
Fetal growth restriction
Multiple pregnancy
Post term pregnancy
Decreased fetal activity
Systemic lupus erythematous or Antiphospholipid syndrome
Sickle cell disease
Oligohydramnios or polyhydramnios
Maternal heart disease
Poorly controlled maternal hyperthyroidism
Maternal vascular diseases
Prior fetal demise
Preterm premature rupture of membranes Associated with oligohydramnios
Preterm premature rupture of membranes Associated with subclinical intrauterine infection
advanced maternal age (above 40)
obesity
abnormalities in first and second trimester Down syndrome maternal analyte screening results
and major fetal structural anomalies
Trauma
Accidental poisoning or medication overdose
Obstetric cholestasis
Chronic renal disease
References:
http://www.uptodate.com/contents/overview-of-antepartum-fetal-
surveillance?source=see_link&sectionName=INDICATIONS+FOR+FETAL+SURVEILLANCE&anchor=H17#H17
*SEHA task force feedback

Outcomes from the task force discussions with respect to ultrasound
Obstetric or non-obstetric?
Known pregnant (even by beta-HCG) use 76817 USG, pregnant uterus, transvaginal
(obstetric), regardless of final outcome (such as 633 Ectopic pregnancy)
Known non-pregnant or pregnancy status unknown consulting due to 789 Abdominal pain
may use 76830 USG, transvaginal (non-obstetric) 76856/76857 USG pelvic (non-obstetric)
regardless of final outcome (viable/non-viable pregnancy present)
Trimester specific?
Re-evaluation and biometry at 32-34 weeks gestation as routine standard (AIUM) use
76805 USG, pregnant uterus, fetal and maternal evaluation, after first trimester; single or
first gestation OR 76811 USG, pregnant uterus, fetal and maternal evaluation plus detailed
fetal anatomic examination single or first gestation NOT 76801 USG, pregnant uterus, fetal
and maternal evaluation, first trimester; single or first gestation
Singleton or multiple pregnancy?

651.xx Multiple gestation use 76801/76805/76811 for first fetus, add
+76802/+76810/+76812 for each additional fetus

Outcomes from the task force discussions with respect to ultrasound continued
Allowed frequency?
76813 USG, pregnant uterus, first trimester fetal nuchal translucency measurement as
screening for fetal aneuploidy optimally at 11 weeks to 13 weeks + 6 days gestation (AIUM)
ONCE per pregnancy if:
>35 yrs,
with family history of Down Syndrome,
suspicious ultrasound
Complete studies 76801 and 76805 ONCE for each per pregnancy
Quick look or complete study?

Checking fetal heart tones throughout the pregnancy use 76815 USG, pregnant uterus,
limited (e.g.. Fetal heart beat, placental location, fetal position, amniotic fluid volume) NOT
76805
Initial or follow-up study?

Pathologic condition identified by previous scan or needs monitoring use 76816 USG,
pregnant uterus, follow-up, per fetus
Mutually Exclusive?
Do not report more than one pregnancy ultrasound for the same encounter (unless specified
in the coding such as each additional)
E.g. CPT codes 76801 and 76811 in the same claim.

Review Outcome Breakdown by denied amount for 2015
Additional diagnosis or specificity

required within the reported diagnosis
No correlation between
reported diagnosis and service 10%
22%
28% Under review
40%
Payable After review & discussions
with Obs_Gyn point of contact

Examples of Claims where there was no correlation between reported diagnosis
service
Diagnosis Code Diagnosis Description
V22.0 Supervision of normal first pregnancy
Case Procedure Code Procedure Description

76816 Ultrasound, pregnant uterus, real time with image
documentation, follow-up (e.g. Re-evaluation of
fetal size, organ system(s) suspected or confirmed
to be abnormal on a previous scan), trans-
abdominal approach, per fetus

V22.1 Supervision of other normal pregnancy
Case V23.7 Supervision of high risk pregnancy, with
insufficient pre-natal care
Procedure Code Procedure Description
59025 Fetal non-stress test
Looking at the sample Claims provided above, we could not find any
correlation between the reported diagnosis and service.
service
637.92 Unspecified abortion, without mention of

complication, complete
Case
detailed fetal anatomic examination,
transabdominal approach; single or first gestation

648.91 Other current conditions classifiable elsewhere
of mother, delivered, with or without mention of
antepartum condition
Case 729.1 Myalgia and myositis, unspecified
Looking at the sample Claims provided above, we could not find any
service
V25.40 Contraceptive surveillance, unspecified

Case
626.4 Irregular menstrual cycle
Procedure Code Lab Procedure Description
82306 Vitamin D Lab test
Case V22.1 Supervision of other normal pregnancy

Procedure Code Lab Procedure Description
80069 Renal function panel
Looking at the sample Claim provided above, we could not find any

service
Supervision of high risk pregnancy with elderly

V23.81 primigravida
Case
V28.6 Antenatal screening for Streptococcus B
87070 Culture, bacterial; any other source except
urine, blood or stool
Looking at the sample Claim provided above, we could not find any correlation between
the reported diagnosis and service. The more reflective code would have been
87081 Culture, presumptive, pathogenic organisms, screening only.

Examples of Claims where additional diagnosis or specificity required within the
reported diagnosis
648.83 Abnormal glucose tolerance of mother,

antepartum condition or complication
V68.09 Other issue of medical certificates
Case Procedure Code Procedure Description
76816 Ultrasound, pregnant uterus, real time with
image documentation, follow-up (eg. Re-
evaluation of fetal size, organ system(s)
suspected or confirmed to be abnormal on a
previous scan), transabdominal approach,
per fetus
Looking at the sample Claim provided above, Looking at the sample Claim provided
above, an additional code that would have completed the picture could have been
790.22 Impaired glucose tolerance test (oral).

Examples of Claims additional diagnosis or specificity required within the reported
diagnosis
V23.9 Supervision of unspecified high-risk

pregnancy
648.13 Thyroid dysfunction of mother, antepartum
Case condition or complication
478.19 Other disease of nasal cavity and sinuses
Lab Procedure Code Lab Procedure Description
84443 Thyroxine, free
Looking at the sample Claim provided above, an additional code that would have
completed the picture could have been ICD from 240-246 series.

Examples of Claims where additional diagnosis or specificity required within the
reported diagnosis
V72.42 Pregnancy examination or test, positive

result
Case 112.2 Candidiasis of vulva and vagina

76805 USG, pregnant uterus, fetal and maternal
evaluation, after first trimester; single or first
gestation
Looking at the sample Claim provided above, an additional code that would have
completed the picture could have been
Chapter 11 Complication of pregnancy, childbirth and the puerperium (630-
679), V22.2 Pregnancy incidental, NOS, etc.

Closing Remarks
In the event a Denial for a service is received from DAMAN which is justified, there are
means to Rectify:
1. 2 resubmission attempts : 2000 character description allowed per service denied.
2. Arbitration channels - emails to:
o SEHAclaimsqueries <SEHAclaimsqueries@damanhealth.ae>
o MSRQueries <MSRqueries@damanhealth.ae>
3. Meetings with Daman providing best practice evidence ( such as this forum)
4. This workshop is all about how you can contribute to better comprehension of your
claims
Your Feedback is ESSENTIAL for the success of this initiative!

Thank You
For more information visit
www.damanhealth.ae

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Welcome to Daman

SEHA_DAMAN Denial Workshop

Doudle Carmela Magcalas,

23/03/2016 SEHA Workshop 2

3. Claims Process Cycle

4. Medical Necessity Review in DAMAN

5. SEHA_DAMAN Denial Discussions

23/03/2016 SEHA Workshop 3

Access to Quality of Reduction of

23/03/2016 SEHA Workshop 5

Preparation & Setup Phase 2 Rollout

2005 2006 2007 2008

1st May 2006 1st July 2006 June 2008

23/03/2016 SEHA Workshop 6

Daman falls under the supervision of different regulators.

23/03/2016 SEHA Workshop 7

23/03/2016 SEHA Workshop 8

23/03/2016 SEHA Workshop 9

Basic Enhanced Portfolio Thiqa

23/03/2016 SEHA Workshop 10

2 - XML Remittance Advice

23/03/2016 SEHA Workshop 12

23/03/2016 SEHA Workshop 13

23/03/2016 SEHA Workshop 14

23/03/2016 SEHA Workshop 15

Claims judgment is based on the below criteria:

Member Age and Gender

Provider Network Eligibility

Coverage and Exclusions of Insurance benefits

Coding and Billing Rules

Medical Necessity and Published Guidelines

23/03/2016 SEHA Workshop 16

A sample of the data received on a Claim:

23/03/2016 SEHA Workshop 17

Once a Claim Passes all the previously highlighted checks, it will be

None of the physician EMR notes are transferred on E-claim sent to

Judgment is based on the one to one co-relation between the submitted

Whether in the Human or Automated review, best practice evidence is used

23/03/2016 SEHA Workshop 19

2 resubmission attempts : 2000 character description allowed per service

Arbitration channels - emails to:

Meetings with Daman providing best practice evidence ( such as this

23/03/2016 SEHA Workshop 20

At the time of adjudicating the claims, our decisions regarding the

23/03/2016 SEHA Workshop 21

Will the Diagnosis Codes justify

23/03/2016 SEHA Workshop 22

Diagnosis Code Claimed Diagnosis Description

23/03/2016 SEHA Workshop 23

Diagnosis Code Claimed Diagnosis Description Daman Review

* MNEC-005: Service/supply may be appropriate, but too frequent

Diagnosis Claimed Diagnosis Description Daman Review

Now the claim is fully payable!

23/03/2016 SEHA Workshop 25

As per Coding rules, in the outpatient setting a diagnosis SHOULD NOT be

Some coding rules for the obstetric setting:

Do not Code V22.0 (Supervision of normal first pregnancy), V22.1 ( Supervision

23/03/2016 SEHA Workshop 28

23/03/2016 SEHA Workshop 29

23/03/2016 SEHA Workshop 30

23/03/2016 SEHA Workshop 31

Singleton or multiple pregnancy?

23/03/2016 SEHA Workshop 32