Takafulamanh offers franchisees the tools and expertise to fully manage their network of healthcare providers and administer health insurance claims from pre-certification of admissions and service provision to case management, claims adjudication and payment settlement. The process is facilitated by an e-claims portal available to Takafulamanh’s healthcare providers’ networks, allowing them to verify the patient’s eligibility, based on policy-defined benefits and medical necessity, and process claims online at every step of the patient service cycle.

In addition, our franchising model gives franchisees access to the following services:

Preferred Provider Network:

Takafulamanh Saudi has invested time and effort in creating a wide and extensive network of qualified CCHI registered providers.  Our networks include a wide selection of hospitals, polyclinics, pharmacies, dental clinics and diagnostic centers throughout the Kingdom.  Our ability is magnified when catering to clients in remote regions.

• Provider Selection Criteria:

 - License by MOH and certification by CCHI before obtaining the Takafulamanh Saudi stamp of approval.

 - Geographic reach, localities in underserved remote areas.

 - Specialty and service requirements.

 - Preferential Tariff/Agreements-not dependent on size.

• Tailored Network Design:

Our vast network of Providers gives us the ability to differentiate networks specifically to our customer’s needs and locality.

 - Exclusive Provider Network.

 - Limited Provider Network.

This is supported by our online facilities with the added function of “Direct Billing,” with remote processing and protocol compliance.

Admission and Medical Review:

• Eligibility Control:  The use of our application system and processes, set up with providers, enables us to determine the eligibility of adherents requiring access to services requested, and, or access to particular providers within the assigned network.  Our access cards are used as the principle method of identity control in line with the table of benefits supplied to providers for quick and easy reference-magnetic strip.

• Concurrent Review:  Our medical professionals diligently apply medical protocols based on the principles of usual, customary and reasonable treatment.  Our roving doctors and delegates review medical files and consult with attending physicians to ensure that the most appropriate treatment is given to the insured.  The concurrent review is our proactive means of containing costs, and focus is placed on the patients’ length of stay and case management.

Claims Processing and Audit:

Our investment in technology and staff supports a strong claims management cycle that processes claims from multiple sources and formats. All claims are analyzed in a systematic manner for the purpose of minimizing benefits abuse and misuse. We further protect the insurance company’s benefits by closely monitoring utilization levels and identifying potential cost containment measures.

Third Party Accounting:

Transparency promotes cooperation – Financial reporting for Guarantors & Providers. This consists of collection from risk carriers, settlement to medical service providers and accounts reconciliation.

• Provider Accounts: Our providers can access their accounts online, which are updated instantly, regarding bills issued for services rendered.  These reports provide details concerning approved claim amounts, adjusted amounts, settled amounts and “aging of payments due.”  In addition, we have e-banking facilities designed to expedite payments to providers via on-line bank transfers.

• Guarantor Accounts:  Our applications are designed to promote a complete segregation of accounts.  Customers can access their online Statement of Accounts regarding claims payments to providers.  These reports provide details concerning approved claim amounts settled amounts and “aging payments due.”  They are also provided with access to “Joint Bank Accounts,” where they can review balances and transactions online, thus conduct timely reconciliations.

• Balance Confirmations & Reconciliations:

 As a result of our online facilities and transparency given to both Guarantors and Providers alike e-banking facilities designed to expedite payments to providers:

- Guarantors’ and Takafulamanh statement of accounts are compatible, thus promoting prompt payment to providers.

- The time involved in obtaining Balance Confirmations and ultimately Quietus sign off as per reconciliation is minimized and issueless.

Regulatory Compliance & Reinsurance Reporting Support:

Reporting for Re-Insurance Compliance:Our analytical expertise and specialized tools (COGNOS & SAS) allow us to support you fulfill the reporting requirements to your Re-insurer. Our effectiveness as a TPA and our data capturing capabilities combined with our qualified analysis, define us as a credible source of performance reported by all major re-insurers.

Regulatory Compliance Reports:SAMA report is required once a month by all Guarantors; a complex task made effortless with the help of our statistics and reporting unit. CCHI report is a monthly requirement, as it provides a means for monitoring the Guarantors commitment to paying claims for services rendered by providers.

Unique Services:

Following our promise to an uncompromising commitment to excellent Customer Service, we have expanded our Services to include the following:

Field Delegates

Always By Your Side

Delegate Offices are available to render necessary support to the insured members, through facilitating Admission procedures, Reception of Members, Coordinating access to services, and On-spot issues and complaints resolution.

Takafulamanh Saudi Delegates’ Offices are currently present in 13 hospitals.

Call Center

We Would Love To Hear From Our Customers

Our Call Center Help desk and Complaint desk is available 24/7. By calling the number on the back of your Insurance Card, our Call Center agents will assist in any kind of inquiries (Network/Approval/Policy Information…) and raise   complaints through the CRM complaint desk. An SMS will be received once a Complaint is opened and once it is closed.

Prestigious Care Service:

Experience A Care Like No Other

Insured members will benefit from an extraordinary care. As soon as they present their Insurance Card at the Provider, they will be directly contacted by a Prestigious Care Service Agent to ensure they are being well served and to provide support whenever needed.

Chronic Medication Posting Program:

As Easy As It Can Be

Through this program, insured members can collect their medications immediately without prior approval upon presenting their Insurance Card at any pharmacy under the assigned network. All they have to do is to submit Chronic Medication Form & supporting documents to their HR Department once a year.

Reimbursement Tracking Tool:

Don’t Wait For Updates…Get Your Own

Insured members will benefit from a new tool for tracking their Reimbursement Claims.

Through the given application number, the user will be able to track the status of his/her reimbursement from Submission until Payment.