PremierMember Guideالــــدانــــة

Essence Of Care......للعناية جوهرها

Premierالــــدانــــةدليل العضوية

Welcome Valued Saudi Enaya Members

It is our pleasure to have you become a valued member of Saudi Enaya. We consider it an honor that you have chosen us to be your health care partner. Our aim is to provide you with the best services and products that meet with your needs.

We invite you to read this membership guide carefully. It contains all of the information that will help you to reach a better understanding of your membership, since it provides essential information regarding your health care benefits. This guide will help you to make use of all quality services from Saudi Enaya and to understand your full range of benefits.

Please contact us for any further information:

Phone In KSA 800 30 100 30 - Outside KSA +966 92 000 41 22

Email care@saudienaya.com

Online www.saudienaya.com

Mail P. O. Box 3528 Jeddah 21481 - Kingdom of Saudi Arabia

Fax +966 2 66 135 14

Address Jeddah, Saudi Arabia, Tahliya Street, First Floor, A.G.Alesayi Building

Note We kindly advise you to save these contacts on your mobile phone for our instant

assistance to be available at your fingertips.

This guide applies to the following Saudi Enaya products and offers different territorial limits:

• Premier الدانه

Territorial Limits: KSA & Worldwide I (Worldwide) or Worldwide II (Worldwide excluding USA, Canada, Europe and UK).

• Enhanced زمرد

Territorial Limits: KSA & Worldwide I (Worldwide), or Worldwide II (Worldwide excluding USA, Canada, Europe and UK).

• Classic ياقوتTerritorial Limits: KSA & Home Country only

• Care فيروزTerritorial Limits: KSA only.

These products are compliant with the regulations set forth by the Council of Cooperative Health Insurance (CCHI) and have been designed to provide you with:

• Choice• Security• Ease of use• Peace of mind

The products cover all mandatory eligible healthcare expenses for you and your dependents as well as additional extras depending on your level of cover.

A Guide to Your MembershipWe have prepared this guide to help you grasp the concept of being a Saudi Enaya member and to understand your membership benefits as well as your responsibilities.

This guide should be read in conjunction with the Table of Benefits that you receive with this guide.

Membership Card

With this package you will be receiving Saudi Enaya Cards for yourself and your eligible dependents. These cards will allow you to access available services at our designated network of hospitals and clinics (Please refer to the enclosed list of our network providers).

Any time you need to visit one of our network providers you need to show your Saudi Enaya membership card, as it shows your membership details. In addition to membership card, please submit your National ID to the staff of the network provider as it is requested for member validation.

Valed for

Co-insuranceThis is the amount you

will be paying directly to hospital/clinic on every

out-patient visit.

Your Membership Number

This is your Enaya membership number

Membership card issue number

Expiry DateYour health coverage is valid until this date

with Saudi Enaya. Room Type This will be your

room category during hospitalization. Maternity Sign

‘Y’ means maternity is covered and ‘N’ means

not covered.

Membership card lost

In case you lose your membership card kindly contact Saudi Enaya customer service. Saudi Enaya will provide you with a replacement card within 24 hours and it’s subject to fees.

Premierالــــدانــــة

Co-Pay OPD: 20% max up to 100 SR.

Expiry Date31/12/2012

YOB 1979

TypeX Suite Room

Gender M

Matemity N

Policy Number.8888National ID: 2012345678

Shaik Abdul Arif Juffali Brothers

Staff NO: 1007Card NO: 9999 1

Membership card details

These are our customer service contacts available

24 / 7

To know more about Saudi Enaya please visit our website.

Saudi Enaya Member Services

Member assistance around the clock (24/ 7)Customer Service contact details are located on the back of your membership card. Our professional and bilingual staff are available to provide the best specialized assistance as follows:

• Guidance and assistance with the selection of providers• Information on your health care benefits• Coordination of emergency assistance• Response to all your inquiries

Online AuthorizationSaudi Enaya’s objective is to provide prompt services to all members. Our Network Providers will be able to access our system via the Saudi Enaya Online Provider Portal for the following:

• View member eligibility• View Table of Benefits• Send authorization request• View authorization status• Receive approvals

SMS ServicesOur instant message service will send text messages to your mobile phone for the following:

• Pre-Authorization request receives by Saudi Enaya • Saudi Enaya replies to the authorization request• To update you with the latest information

Network Provider

Saudi Enaya has developed a comprehensive network across the whole Kingdom with Primary Health Care facilities, General Hospitals as well as Specialized / Referral Hospitals. All providers are accredited by CCHI and have been chosen to provide you with the best available services.

Note:

• Saudi Enaya recommends that you obtain an appointment prior to your provider visit in order to avoid long waiting times.

• A copy of the Network list is included in the membership package and available online on our website. For more details please contact our customer service.

Direct Billing & Reimbursement

Direct BillingFor all the providers in your network (according to the selected product) Saudi Enaya guarantees that you can receive treatment on a direct billing basis. This means that Saudi Enaya will pay for all services rendered to you (within the range of coverage chosen).

You will only have to pay your out-patient co-insurance (according to the selected product) directly to the provider.

If you require services from any provider outside your network as per your table of benefits, you are allowed to proceed on cash basis and submit your invoices for reimbursement, as explained below.

Reimbursement You can utilize services outside of your designated Network Provider, by paying cash for these services and forwarding the invoices to us for reimbursement. The amount will be reimbursed to you as per your product specifications. Please refer to the enclosed Table of Benefits for more details.

All Reimbursement Claims must be submitted with the following original documentations:

• Saudi Enaya Reimbursement form

completed and signed.

• Detailed medical report filled out by your

treating doctor along with his signature,

date and stamp.

• Itemized invoices

• Prescriptions, if applicable.

• Investigation results of any laboratory/

diagnostic reports, if applicable

Please Note: • Reimbursement claims must be received

no longer than 30 days after the date of treatment for services within KSA and 60 days for services availed outside KSA.

• Processing and settlement of your reimbursement claim will take 14 working days upon the receipt of the claim along with required documentation.

PRE-APPROVAL

What is Pre-Approval?Saudi Enaya requires your network provider

to contact us to gain approval for a particular

treatment or service.

This is done to ensure that:

• You are eligible for the treatment or service

under your policy benefits.

• The proposed treatment or service is

medically necessary.

• The proposed treatment or service is within

the reasonable and customary charges of

comparable network Providers.

• There is enough remaining benefit limit on

your membership to cover the treatment or

service cost.

Prior Approval and Notification Requirements

All Inpatient Hospitalization

& Day Cases (Medical & Surgical)

Admission for Emergency cases

Out Patient Services requiring Approval

Other Out Patient Services

(Excluding Consultation

& Medication)

Medication

Maternity

Physiotherapy

Requires Approval

No Approval required, Saudi Enaya should be notified within 24 hours of admission.

Dental & Optical Services, Boys Circumcision & Girls Ear Piercing for new baby born, Chemotherapy & Radiotherapy, Psychiatric Cases,Renal Dialysis, And Hearing Aid.

Premier الدانة : Does not require Approval.

Enhanced زمرد : Requires Approval if total amount exceeds SR 1,000.

Classic ياقوت : Requires Approval if total amount exceeds SR 750.

Care فيروز : Requires Approval if total amount exceeds SR 500.

Acute Cases: Does not require prior approval.

Chronic Cases: Treatment for more than one month requires Approval.

Requires Approval for first visit only.

First session does not require Pre-approval, following sessions

require approval.

Inpatient Services

Out Patient Services

Saudi Enaya will not cover claims arising from:

1. Intentional self-inflicted injury.2. Sicknesses resulting from abuse of some medicines, stimulants or

tranquilizers, or from use of alcohol, narcotics and similar substances.3. Cosmetic treatment or surgery unless necessitated by a bodily injury

not excluded under these exclusions.4. General checkups, inoculations, drugs or preventive measures not

required for medical treatment covered under this policy (excluding preventive measures determined by the Ministry of Health, such as vaccination, maternity and child care.).

5. Pregnancy and delivery treatment of a woman identified in her contract as unmarried.

6. Treatment received by a beneficiary free of charge.7. Rest cures, general health cures and treatment in social welfare

institutions.8. Any illness or injury resulting directly from the beneficiary,s profession.9. Medically recognized venereal or sexually transmitted diseases.10. Costs of treatment following diagnosis of HIV or any disease related to

HIV, including AIDS and its derivatives, alternatives, or other forms.11. All costs related to tooth implants, dentures, fixed or movable bridges

or orthodontic treatment, unless resulting from violent external means.12. Vision or hearing correction tests and visual or hearing aids, unless

requested by a licensed physician.13. The beneficiary,s transportation expenses within and between cities

in the Kingdom by means other than ambulances of the Saudi Red Crescent or licensed ambulances.

14. Hair loss, baldness or artificial hair.15. Psychological, mental or nervous disorders, unless of an acute nature

as specified in the policy schedule.16. Allergy tests of any nature, unless relating to medicines, diagnosis or

treatment.17. Equipment, means, drugs and procedures, or hormone treatment

aimed at regulating reproduction, contraception, fertility, infertility, impotence, secondary sterility, in-vitro fertilization or any other method of artificial fertilization.

18. Any congenital weakness or deformity unless it is life threatening, except for cases requiring treatment in accordance with a medical report issued by the health facility approved by the Council.

19. Any costs or additional expenses incurred by the beneficiary,s companion during a hospital stay, except for the hospital room and board charges for one companion such as a mother companying her child aged up to twelve years or whenever medically necessary as assessed by the attending physician.

20. Treatment of acne or any treatment relating to obesity or weight problems.

21. Organ or marrow transplant, or implant of artificial organs to replace any organ of the body.

22. Any activities known to involve high risk of exposing a person to an illness or an accident, or is expected to aggravate a previous illness or injury.

23. Alternative medicine procedures and medications.24. Artificial and ancillary limbs except those required by the

beneficiary as per a medical decision issued by the health care facility approved by the Council.

25. Natural changes related to menopause, including menstrual disorders.

This policy shall not cover medical benefits or corpse repatriation to home country in claims resulting directly from:

1. War, invasion, acts of foreign enemy, acts of aggression (whether or not war is declared) or civil war.

2. Ionizing radiations, pollution from radioactive activity of any nuclear fuel or waist resulting from the combustion of nuclear fuel.

3. Radioactive, toxic, explosive or other hazardous properties of any nuclear plant or any of its nuclear components.

4. Beneficiary,s service or participation in armed forces or police activities.

5. Riots, strike, terrorism or the like

Note: All exclusions listed above are as per CCHI

easy stepsto benefits from the Health Services5 Always carry your membership card along with

your National ID while visiting the Provider. It is preferable to reach the Provider Reception 15 minutes before your appointment

If services require prior approval from Saudi Enaya, do not worry. The provider will send us the request and get approvals instantly. Simultaneously, you will receive text messages on the status of your authorization.

Familiarize yourself with the enclosed Providers list and choose the one you would like to visit. If you cannot decide, Saudi Enaya Customer Service would be glad to assist you in selecting an appropriate Provider.

Call the Provider to book an appointment with your doctor in order to avoid delay at Provider.

If you face any difficulties receiving services from the Provider, please contact our customer service for assistance.

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Feedback or Complaints

Saudi Enaya is committed to provide the most enhanced

and value adding services to its most esteemed

members. Your feedback or even your complaints will

give us the opportunity to further improve our services

and we can assure you that we will spare no efforts

in providing the best solution and services to meet the

high standard of your expectations.

If you have faced any difficulties related directly or

indirectly to Saudi Enaya’s services or would like to

provide your valuable feedback, please do not hesitate

to contact us inside KSA: 8003010030 or outside KSA:

+966 920004122 or email us at: care@saudienaya.com

DEFINITIONSInsured/Member:

The person (employee or dependent) included under the

scheme

Card Number: A unique number provided to each Saudi Enaya insured member as an identification.

Insurer: Your health insurance company Saudi Enaya Cooperative Insurance Co.

Policyholder: The employer or person in whose name the policy is issued.

CCHI (Council for Cooperative Health Insurance): Regulator for Health Insurance in Saudi Arabia.

Provider:Physician, hospital, group practice, nursing home, pharmacy or any facility, individual or group of individuals that provides a health care service.

Reasonable and Customary: It means that the medical expenses are comparable with the level of fees charged by the majority of licensed doctors

or hospitals in the member’s network in Saudi Arabia. It also means that the medical treatment does not differ significantly from what the licensed doctors consider acceptable for being the usual and customary treatment for any particular service.

Benefits: The costs of providing health services included in the insurance cover within the limits shown in the Table of Benefits.

Applicable Healthcare Benefits: The mandatory benefits as specified in the regulations set

forth by CCHI provide comprehensive coverage. However,

depending on your Saudi Enaya coverage you may receive

higher benefits, Please refer to your Table of Benefits.

Table of Benefits: The attached table of benefit applicable to your plan showing the maximum benefits we will pay for each member.

Coverage: The amount and extent of risk covered by Saudi Enaya.

Standard Exclusions: The health benefits and services excluded from your coverage.

Reimbursement: A method for compensation of expenses incurred by the insured member at a provider.

Direct Billing: The facility of non-payment granted to the insured at the provider appointed by Saudi Enaya whereby all such costs are directly billed to Saudi Enaya by the provider.

Network: All the primary physicians, specialists, hospitals and other providers who participate in this plan to provide your medical care. A list of your network providers is enclosed with this membership package.

Chronic Condition: A medical condition or episode of ill health which persists for a long period.

Pre-existing & Chronic Diseases:All pre-existing and chronic diseases are covered except those listed in the Standard Exclusions.

Medical Report: A document filed by the doctor explaining the symptoms, diagnosis and treatment given.

Emergency: The medical treatment required for an insured person as a result of an accident, or an illness requiring prompt medical attention.

Emergency Treatment:You are covered up to 100% of your annual limit for covered emergency services available outside of your network, subject to the geographical coverage as per your enclosed Table of Benefits

Out-patient Treatment: The Out-patient benefit covers all eligible treatments, procedures and services other than those listed in the Standard Exclusions.

Co-Insurance: Your plan may include a Co-Insurance payment which is the amount that is required to be paid to the provider when you are being treated for an applicable out-patient service. This will be specified on your membership card as a percentage % of the treatment cost with a maximum limit of SAR100.

In-patient Treatment: The In-patient benefit covers all eligible treatments, procedures and services other than those listed in the Standard Exclusions.

Room Type: Depending on your level of coverage, your hospital room will be specified on your membership card as a normal suite, private room, semi-private room or shared room.

Companion Cover:If you have a dependent child that is under the age of 12 or if medically necessary as assessed by attending Physician, Saudi Enaya will pay for a companion to accompany the child during the hospital stay.

Maternity:• Maternity benefits are automatically provided for all

eligible females and will cover the cost of pregnancy, normal delivery, caesarean section and maternity complications including legal abortion and miscarriage. (Please refer to the enclosed Table of Benefits)

• The cost of ear piercing for new born girls and circumcision for newborn boys is also covered under this benefit.

• Maternity coverage is specified on your membership card with a sign indicating your coverage.“Y” means Maternity is covered and “N” means Maternity is not covered.

Dental: Dental benefits cover the cost of consultation, x-rays,

normal and surgical extractions, root canal treatment,

amalgam/composite filling, gum treatment and

prescribed medicines.

Optical: The optical benefit includes consultation, vision tests

and prescription glasses, including frames.