SEPTEMBER 2019 - pulse-uae.tatsh.com

Authors: Stephen Robert Honorio & Nada Asmar

[Grab your reader’s attention with a great

SEPTEMBER 2019

© NEXtCARE – V2019.6 September 2019 Page 2 / 112

Table of Contents

1. System Overview .......................................................................................................................... 3

2. Pre-Requisites ............................................................................................................................... 4

2.1 System Pre-requisites ............................................................................................................. 4

2.2 Data Pre-requisites ................................................................................................................. 5

3. Access ............................................................................................................................................ 6

4. PULSE Support & Emirates Medical Benefits Support ............................................................. 7

5. User Registration and Login ........................................................................................................ 8

5.1 New User Registration ............................................................................................................ 8

5.2 Resetting of Password .......................................................................................................... 12

5.3 Logging into Pulse ................................................................................................................. 18

6. PULSE Main Dashboard ............................................................................................................. 19

6.1 Layout and Overview ............................................................................................................ 19

7. Claims Dashboard ....................................................................................................................... 22


8. Eligibility Checking (Verification) .............................................................................................. 26


8.1.1 Checking for a member’s eligibility to a provider via PULSE (NEXtCARE and Emirates Members) ........................................................................................................................................... 26

8.1.2 Eligibility check results (NEXtCARE and Emirates Members) .............................................. 31

8.1.3 Member ineligibility results .................................................................................................... 31

9. Claims Registration (“Create Claim”) ....................................................................................... 39

9.1 Layout and Overview (Claim Creation for NEXtCARE and Emirates Members) .................. 39

9.2 eAuthorizations and ePrescriptions (DHA), and Claim Modification and Submission via PULSE (DHA and HAAD) .................................................................................................................. 67

9.3 Gatekeeper Protocol (eReferral Procedure) ......................................................................... 77

10. Guarantee of Payment Issuance via PULSE ............................................................................ 82

10.1 Creation, Submission, & Modification of GOP Requests ...................................................... 82

10.2 Tracking/Searching of GOP Requests .................................................................................. 89

11. Search .......................................................................................................................................... 82

11.1 Claim Search ......................................................................................................................... 82

11.2 Batch Search ......................................................................................................................... 85

11.3 Claims Summary ................................................................................................................... 87

12. Claims Delivery ........................................................................................................................... 98


12.2 Claims not yet delivered ........................................................................................................ 98

12.2.1 Claims Batches ............................................................................................................. 98 12.2.2 Claims not delivered ...................................................................................................... 99

12.3 Upload Batch ....................................................................................................................... 101

12.4 e-Bills History ...................................................................................................................... 102

13. Inbox ........................................................................................................................................... 103

14. Settings ...................................................................................................................................... 104

14.1 Change Password (please also refer to section 5.2) .......................................................... 104

14.2 Upload Logo ........................................................................................................................ 104

14.3 Post Office Credentials (please also refer to section 9.2) ................................................... 107

14.4 Manage Users ..................................................................................................................... 108

15. Help ............................................................................................................................................. 112


PULSE is a web-based application that is offered by NEXtCARE to its own network of healthcare providers (e.g. hospitals, clinics, pharmacies, etc.) and also to the Emirates Airline’s as well, to facilitate real-time transfer of information between both parties (NEXtCARE or Emirates and the providers). PULSE will allow its users to register pre-approval requests on-the-spot, obtain pre-certification responses from NEXtCARE/Emirates (whether it is authorized, pending for manual review, or declined), deliver pre-certified claims to NEXtCARE/Emirates at the end of every billing cycle (claims’ submissions for processing and settlement), monitor preapprovals and claims’ statuses and extract reports for claims’ reconciliation, upload e-bills, generate electronic statements of settled claims, and receive notifications from NEXtCARE/Emirates (in the form of circulars and messages).

Benefits gained when using PULSE:

Instantly view current insured-patient benefit information.

Provides an all-in-one platform for healthcare provider facilities to communicate claim-related transactions to and from NEXtCARE/Emirates (prior approval requisitions, claims’ submissions, claims’ reconciliation, etc.) and to verify the eligibility of visiting members without the need to contact NEXtCARE/Emirates.

It also facilitates faster responses to pre-certification requests due to the pre-configured systemized medical controls and edits and “ICD-CPT/CDT/drug codes crosswalks” applied for every pre-approval request that is registered via PULSE. It is designed to auto-adjudicate pre-approval requests (determines whether it will be auto-authorized, auto-declined, or queued for manual review), which in turn significantly improves the average turnaround time on claim responses.

Electronically transfer and upload pre-approvals and claims from the Provider’s Hospital Information System (HIS) to PULSE.

Aids in submitting complete and accurate claims which results in a faster average turnaround time.

24/7 access to claim information for both past and present preapprovals and claims. Helps maintain records and keep track of claims and payments.

Upload e-bills to expedite the audit and thus the payment process as well.

Can be utilized as a primary tool for providers to monitor claims’ settlement notifications received from NEXtCARE/Emirates.

1. SYSTEM OVERVIEW


The following pre-requisites are crucial for the implementation of PULSE and are necessary to have such setup and made available at the healthcare providers’ facilities.

2.1. System Pre-requisites

TABLE 1: SYSTEM PRE-REQUISITES

S. NO. DETAILS NOTES

1 On Site Access to a computer (desktop or laptop), scanner, and printer.

2 Internet

Connection

Access to the internet, without any firewall restrictions on all related proxy

servers, for the following URL to be accessed:

https://pulse-uae.tatsh.com/Login2.aspx?s=2

3 Internet Browser

The updated versions of the preferred browsers are to be used:

1. Google Chrome 2. Internet Explorer (Version 9 and above) 3. Microsoft Edge 4. Mozilla Firefox 5. Safari

4 Operating

System 1. Windows 7 and above, XP, or Vista 2. Mac OS (OS X Mavericks and above)

5

Software

applications and

Programs

The updated versions of the following software applications are to be installed:

1. Updated Version of PDF Reader (Adobe Acrobat, Nitro, etc.) 2. Microsoft Office

6 Pop up Blocker To be disabled or customized (which will allow all pop-up windows from PULSE).

7

DHPO or HAAD

PO credentials

(currently

applicable to the

UAE only)

In order to enable eAuthorizations via PULSE (for all Dubai-based providers

sending eClaims via the DHPO), claim submissions via PULSE (for all

pharmacies submitting eClaims via the DHPO and HAAD PO), and/or direct claim

modifications via PULSE (for all providers submitting eClaims via the DHPO and

pharmacies submitting eClaims via the HAAD PO), please refer to section 9.2,

page 67 of this user guide and contact PULSE Support for further assistance at

+971042708559.

2. PRE-REQUISITES



2.2. Data Requisites

S. NO. DETAILS NOTES

1

Service

Procedure

Pricelist

Current agreed pricelist must be CPT/CDT-coded and sent to NEXtCARE or to the

Emirates Medical Benefits team in the table format provided below.

S. No. Description

Type

Full

Description

CPT

Code

Gross Discount Net

Price

Remarks Internal Code

2 Drug List Regional MOH/DHA/HAAD drug lists as mandated by the regulator. All concerned users

at the providers’ end must have access to these lists.

3 Clinicians

Details List

An updated list of the providers’ clinicians must be sent to NEXtCARE or to the Emirates

Medical Benefits team in the table format provided below along with copies of their

licenses.

CLINICIAN NAMES (AS PER THEIR

LICENSE CARDS)

LICENSE NUMBERS (AS PER THEIR

LICENSE CARDS)

SPECIALIZATIONS (AS PER THEIR LICENSE

CARDS)

Providers are to notify NEXtCARE or the Emirates Medical Benefits team, hence, of

any new clinicians who join their teams, so that records can remain current and the

same can reflect in PULSE for their claim requests.

4 Nominated

Users List

An updated list of Assigned/Nominated users who will be using PULSE must be sent to

NEXtCARE or to the Emirates Medical Benefits team in table format provided below for

initial user registration requests only.

PROVIDER NAME FULL NAME JOB TITLES ACTIVE BUSINESS EMAIL ADDRESS

Providers are to notify NEXtCARE or the Emirates Medical Benefits team, hence, of

any users who join or leave their organization so that the respective user accounts can

be activated or deactivated.

5 Provider

Logo

Provider logo can be in any of the commonly used image formats (e.g. JPEG, GIF,

BMP, etc.) and can be uploaded by the user themselves.

TABLE 2: DATA PRE-REQUISITES


To access PULSE, open any of the aforementioned preferred browsers, and insert the following URL in the address bar and then click “enter”. https://pulse-uae.tatsh.com/Login2.aspx?s=2 The PULSE Login page will be displayed as a result (please refer to figure 1). The PULSE Login page is the first screen displayed when the site is accessed. It also provides the user with basic information such as – security hints, PULSE Support contact details, an overview of its the benefits of PULSE, PULSE FAQs, and a link to NEXtCARE’s website for new facilities which are interested to join NEXtCARE’s network. For any inquiries or assistance required while using PULSE for members of the Emirates Airline, the user may contact the Emirates Medical Benefits support team (not PULSE Support).

FIGURE 1: LOGIN PAGE

3. ACCESS



Should the user require any assistance while using PULSE for NEXtCARE or Allianz members, they

may contact NEXtCARE on the details below which are the 24/7 support lines. The details are also

indicated on PULSE’s login page for easy reference (please refer to figure 1).

Email: [email protected]

Phone: +971 4 2708559

If the provider facility is located outside the UAE, the user may contact the respective Call Centre/Helpdesk numbers in that region and request to be connected to NEXtCARE’s PULSE Support.

On the other hand, for any inquiries or assistance required while using PULSE for members of Emirates Airline, the user may contact the Emirates Medical Benefits support team as seen in the details below.

Email: [email protected]

Phone: +971 4 7085508

4. PULSE SUPPORT & THE EMIRATES

MEDICAL BENEFITS SUPPORT

mailto:[email protected]


5.1. New User Registration

Overview

To log in to PULSE, the user must first have a username and password which is provided only by NEXtCARE.

To obtain these login credentials, the user must send a “New User Registration” request to NEXtCARE via PULSE.

NEXtCARE or the Emirates Medical Benefits team will then verify the request with the Provider Management, prior to issuing the login credentials to the user, wherein the provider will receive an automated email as a notification of such.

The provider is responsible for notifying NEXtCARE or the Emirates Medical Benefits team if any new personnel join or leave their organization, so as to have the respective user accounts activated or suspended.

It is always important to remember never to share login credentials with other users for confidentiality reasons and in order to meet the high security standards set by NEXtCARE.

During the initial enrollment of the provider on PULSE, if the users’ details were sent to NEXtCARE via email in the format indicated in the table 2, section 4, please note that the PULSE User IDs will be sent via email as well back to the provider and the password to be used for initial login will be the default password that is 0000.

Steps to be followed to register a new user request

Click on “Create here” as seen in figure 2 below. The “New User Registration” screen will appear as a result (please refer to figure 3).

FIGURE 2: NEW USER REQUEST REGISTRATION (LOGIN PAGE)

5. USER REGISTRATION AND LOGIN


The new user request registration screen is composed of 3 main sections; namely, the

personal information section, business information section, and the account information

section (please refer to figure 3).

All of the fields marked with an asterisk (*) are required to be duly accomplished.

The preferred password must be a minimum of 8 characters in length and must comprise of

a complex combination of at least one from each of the following characters (spaces are not

accepted):

Lowercase Letters (a, b, c...) Uppercase Letters (A, B, C…) Special Characters (*& %#@…) Numbers (1, 2, 3...)

When resetting passwords, the new ones must not be similar to the last 12 passwords that were used.

Once all the fields have been filled out with the required details, the save button is to be clicked

in order to submit the request to NEXtCARE for review. An automated email will be sent to the

email ID that was registered along with the username request, notifying the provider that the

request has been received by NEXtCARE (please refer to figure 4).

NEXtCARE will then verify the user registration’s authenticity with someone in authority (team

leader, supervisor, manager, etc.) from the requesting facility, prior to issuing the PULSE user

ID or rejecting the request.

Whether the user registration request has been approved or rejected, the requesting facility will

receive an automated email with NEXtCARE’s response (please refer to figures 5 and 6).


FIGURE 3: NEW USER REQUEST REGISTRATION SCREEN

FIGURE 4: PULSE NEW USER REGISTRATION REQUEST PENDING NOTIFICATION


FIGURE 5: PULSE NEW USER REGISTRATION REQUEST APPROVAL NOTIFICATION

FIGURE 6: PULSE NEW USER REGISTRATION REQUEST REJECTION NOTIFICATION


5.2. Resetting of Password

Overview

In order to meet NEXtCARE’s standards and guidelines, PULSE passwords impose high security

standards.

The password has a validity of 60 days and a reminder prompt is automatically set to notify the

user to change the password, 10 days prior to its expiry.

If the user logs in to PULSE during the last 10 days of the password validity, an alert message -

“Your password will expire in N days” will be displayed, to remind them to change their password.

If the user logs in to PULSE after the password validity is exceeded, they will automatically be

directed to the change password screen, where they will change their password in order to continue

to any other screen in PULSE.

The preferred password must be a minimum of 8 characters in length and must comprise of a

complex combination of at least one from each of the following characters (spaces are not

accepted):

o Lowercase Letters (a, b, c...) o Uppercase Letters (A, B, C…) o Special Characters (*& %#@…) o Numbers (1, 2, 3...)

If the user logs in to PULSE after the password validity is exceeded, they will automatically be

directed to the Change Password screen, where they will change their password in order to continue

to any other screen in PULSE.

The new password must not be similar to the previous 12 changes.

The password can be reset from the login page (if the user forgets his/her own password or is

unable to log in to PULSE using such for some other reasons) or after the user logs in to PULSE.

Guidelines in resetting a password from the login page

Click on “Forgot password?” as seen in figure 7. The “Reset Password” screen will appear as a result (please refer to figure 8).


FIGURE 7: FORGOT PASSWORD LINK (LOGIN PAGE)

The user will be given 2 options to choose from on how their password will be reset.

By email address (please refer to figures 9, 10, and 11)

o A valid and active email ID must first be registered with the username before this method

can be used to reset the password.

o If there is currently no email ID registered with the username or if the user wishes to update

such, the user must send an email to the Pulse Support to request such, as it can only be

done from NEXtCARE’s or from Emirates’ end.

o If the password reset attempt is successful, the user will be directed to the change

password screen (after clicking the password reset link that is received from the registered

email ID).

By secret question and answer (please refer to figure 13)

o The secret question and answer will be set-up when requesting for a new username during

the new user registration request phase (please refer to section 5, figure 3) or if the

usernames are provided by NEXtCARE directly via email (especially for those facilities that

will be using PULSE for the first time), it can be set-up by the user after initially logging in

to PULSE.

o Once it has been set-up, it currently cannot be changed by the user or by

NEXtCARE/Emirates.

o If the password reset attempt is successful (by means of entering a correct answer to the

secret question), the user will be directed to the change password screen (please refer

to figure 12).


FIGURE 8: RESET PASSWORD SCREEN (FROM LOGIN PAGE)

FIGURE 9: RESETTING OF PASSWORD BY EMAIL ADDRESS (FROM LOGIN PAGE)


FIGURE 10: SUCCESSFUL PASSWORD RESET BY EMAIL ADDRESS (FROM LOGIN PAGE)

FIGURE 11: PASSWORD RESET LINK (RECEIVED AT THE REGISTERED EMAIL ID)


FIGURE 12: CHANGE PASSWORD SCREEN (AFTER CLICKING THE PASSWORD RESET LINK RECEIVED AT THE

REGISTERED EMAIL ID OR AFTER CORRECTLY ANSWERING THE SECRET QUESTION)

FIGURE 13: RESETTING OF PASSWORD BY SECRET QUESTION AND ANSWER (FROM LOGIN PAGE)


Guidelines in resetting a password after logging into PULSE (main menu)

After logging in PULSE, the user navigates through the main menu, which is at the left side of the

screen, and clicks on settings (please refer to figure 14), and the change password screen will

be displayed (please refer to figure 15).

The new password must then be used when the provider logs out of PULSE and then logs back in

again.

FIGURE 14: CHANGE PASSWORD - MAIN MENU SIDEBAR (AFTER LOGGING IN PULSE)

FIGURE 15: CHANGE PASSWORD SCREEN (AFTER LOGGING IN PULSE)


5.3. Logging into Pulse

Overview

To log in to PULSE, the user must navigate to the login section located on the first screen that will

be displayed when the site is accessed and enter his/her user credentials correctly (username and

password; please refer to figure 16).

FIGURE 16: PULSE LOGIN SECTION

The remember me box can be ticked if the user prefers not to enter his/her user credentials every

time there is a need to log in to PULSE (please refer to figure 16). However, such option is not

recommended for those who are sharing desktops/laptops, as every user’s credentials must be

confidential to the owner(s) alone.

The user must not include any spaces in both the username and password as such will prevent

the user from logging in successfully to PULSE.

Usernames and passwords used to access PULSE are both case-sensitive; hence, usernames

should be entered exactly the way it was provided to the user and in the case of passwords, the

way that the user/owner created it.


6.1. Layout and Overview

The PULSE main menu sidebar is the core section in PULSE. It is the focal point wherein all the features of PULSE can be navigated from. This will only be available once the user is logged in to PULSE.

FIGURE 17: MAIN MENU SIDEBAR (PULSE MAIN DASHBOARD)

The legend below summarizes all the main information and functionalities available on PULSE’s main menu sidebar (please refer to figure 17).

1 – PULSE portal logo

2 – Users’ facility’s logo

3 – Users’ facility’s name registered with NEXtCARE or Emirates

4 - Current username logged in PULSE

6. PULSE MAIN DASHBOARD

1

2

3 4

5

6

7

8

9

10

11

12


5 – Claims Dashboard (please refer to section 7)

The section of PULSE wherein the status of any claims registered via PULSE or which are

saved in NEXtCARE’s or Emirates’ system (e.g. claims registered via a third-party application

that are successfully received by NEXtCARE/Emirates or claims which were manually entered

from NEXtCARE’s or Emirates’ end) can be monitored.

Only those claims which are currently active (hence, not yet having the status of expired or not

used) and were just registered or updated anytime within 7 days from the current date, and

have not been batched and processed yet, can be tracked and/or manipulated in this section

of PULSE.

Clicking on this will direct the user to the main “Claims Dashboard” page.

6 – Eligibility Checking (please refer to section 8)

The section of PULSE wherein the users will be able to verify whether or not a visiting member

is eligible to avail of their facility’s services, whether or not a visiting member is eligible for a

specific service type, to verify if the member’s insurance policy is still active/valid or otherwise,

and also where the electronic claim form (eASOAP form) can only be obtained from (but only

if the member is eligible and only applicable for NEXtCARE/Allianz members).

Clicking on this will direct the user to the main “Eligibility Checking” page.

7 – Create Claim (please refer to section 9)

The section of PULSE wherein the users from the providers will be able to register their claims

for adjudication.

Clicking on this will direct the user to the “Claim Registration” page.

8 – Claims Delivery (please refer to section 11)

The section of PULSE wherein the users from the providers can upload claims that were

manually batched in an .xml or excel format, which are received by NEXtCARE for processing

and settlement.

9 – Search (please refer to section 10)

The section of PULSE wherein the users from the providers will be able to browse and monitor

any of their claims, regardless of its status (e.g. processed or not, active or expired, settled or

otherwise, etc.) and its mode of submission or where the approvals were obtained from, as long

as it has been successfully received by NEXtCARE/Emirates or were manually entered and

saved from NEXtCARE’s or Emirates’ end.

Reports can also be generated from this section of PULSE, for claims’ reconciliation purposes

and for the providers to identify the details of any remittance advice or other forms of claims’

settlements that they receive.

Clicking on this will direct the user to the “Search” page.

10 – Inbox (please refer to section 12)

The section of PULSE wherein various circulars and other provider-specific notifications can

be communicated from NEXtCARE to the users from the providers.

Clicking on this will direct the user to the “Inbox” page.

11 – Settings (please refer to section 13)

The section of PULSE wherein the users from the providers can change their passwords

(after successfully logging in), upload their facility’s logo for PULSE, connect their PULSE

account to their respective electronic post office accounts (HAAD PO or DHPO), or to

manage the functionalities that can be accessed by each of the active users of PULSE

in their respective facilities and also to deactivate inactive usernames and to remotely

reset each users’ passwords as well (even without such users having to log in to

PULSE).

It has 4 divisions, namely: Change Password, Upload Logo, Post Office Credentials, and

Manage Users, which if clicked, will direct the users to the main page of the option that is

selected.


12 – Help

The section of PULSE wherein the users from the providers can access an electronic copy of

this user guide and a list of the PULSE FAQs as well

Clicking on user guide or FAQs will open the PDF file of the respective option that is selected.

The PULSE main dashboard header and footer (refer to figures 18 and 19)

FIGURE 18: HEADER (PULSE MAIN DASHBOARD)

FIGURE 19: FOOTER (PULSE MAIN DASHBOA1RD)

13 - Logout

This will only be displayed if the user is currently logged in to PULSE

Clicking on this will log the user out of PULSE, back to the login page.

14 – NEXtCARE copyright declaration and current active version of PULSE

15 – PULSE connection’s current date and time (as per the user’s geographical time zone)

13

14 15



The PULSE claims dashboard is the section of PULSE wherein the status of any claims registered via PULSE or which are saved in NEXtCARE’s or Emirates’ system (e.g. claims registered via a third-party application that are successfully received by NEXtCARE/Emirates or claims which were manually entered from NEXtCARE’s or Emirates’ end) can be monitored.

Only those claims which are still within the 7-day period from its initial transaction dates (not yet expired) and have not been batched and processed yet, can be tracked and manipulated in this section of PULSE. However, even if any preapproval is more than 7 days old (and not yet submitted for processing or has expired), but any information in it has been updated, such will still reflect in the claims dashboard, as long as the last update date is still within 7 days from the present date.

It is comprised of 4 main sections, namely: Auto-authorized claims, Pending claims, Pre-certified claims, and Expiring Soon.

Please refer to figures 20 and 21.

FIGURE 20: CLAIMS DASHBOARD SCREEN (1)

1 2 3 4

5

7. CLAIMS DASHBOARD


FIGURE 21: CLAIMS DASHBOARD SCREEN (2)

The legend below summarizes all the main information and functionalities available on PULSE’s claims dashboard (please refer to figures 20 and 21).

1 – Auto-authorized claims

One of the 4 main sections of the claims dashboard wherein the users from the providers will

be able to browse their claims which have the status of auto-authorized. Such claims are those

that were auto-adjudicated by the system, with the members’ policies and the preset system

and medical rules as its bases, and were eventually authorized (can be fully or partially

authorized).

Clicking on this will cause the list of all the auto-authorized claims to appear below it (arranged

by the ones with the most recent last update dates by default, which can be set oppositely by

clicking the button).

2 – Pending claims


be able to browse their claims which have the status of either Pending for Precertification,

Pending for Provider Response, and Pending for Payers Response, and Pending for

Beneficiary Response. Such claims are those in which adjudications are still in progress, with

the members’ policies and the preset system and medical rules as its bases, wherein further

information, documentations, and/or scrutiny are required in order to eventually come up with

a decision to either authorize or decline the claims.

Once that claims available in this section have been finally adjudicated, whether it is authorized

or declined or if the claims have expired, after refreshing the claims dashboard screen, such

claims will not be seen in this section anymore as it will be in the pre-certified claims section

of the said dashboard.

Clicking on this will cause the list of all the pending claims to appear below it (arranged by the

ones with the most recent last update dates by default, which can be set oppositely by clicking

the button).

6

7 8

9

10 11 12 13 14 15 16 18

17


3 – Pre-certified claims


be able to browse their claims which have the status of either Authorized or Declined. Such

claims are those which previously had the status of pending which were manually reviewed

and eventually approved or rejected by the adjudicator.

Clicking on this will cause the list of all the available authorized and declined claims to appear

below it (arranged by the ones with the most recent last update dates by default, which can

be set oppositely by clicking the button).

If the user posts additional notes or uploads attachments to claims which have the status of

authorized (and auto-authorized), its status will change to pending for precertification

(hence its placement in the claims dashboard will also be changed accordingly).

4 – Expiring Soon


be able to browse their claims which are nearing its expiry date or those which already have

the status of expired. A claim expires if it has not been submitted, batched, and processed

within 90 days from its initial transaction date, unless the claim has been cancelled

(wherein, it will have the status of not used). Expired claims cannot be submitted by the

providers any longer; hence, such will not be settled and paid.

If a claim is 10 days away from its expiry date, it will be displayed in this section of the claims

dashboard. Such should alert the providers to either submit such claims at the soonest time

possible prior to its expiry.

Clicking on this will cause the list of all the available claims nearing its expiry dates and those

which already have the status of expired to appear below it (arranged by the ones with the most

recent last update dates by default which can be set oppositely by clicking the button.

5 – Revert to old version

The user will be taken to the original version of PULSE (skin 1) and logged out if this is clicked.

6 – Label of the currently selected section of the claims dashboard

By default, only claims which have last update dates that are 7 days from the current date

of search will be displayed.

7 – Number of claims per search

By default, a maximum of 10 claims can be visibly displayed per search for each of the main

sections of the claims dashboard.

Such can be adjusted by clicking the button and selecting the desired number of

claims that will be visibly displayed.

8 – Search bar

The users will be able to specifically search for claims in any of the main sections of the claims

dashboard by using either one of the following information from the claims:

o Last update date

o Service date

o Reference #

o Card #

o FOB (class)

o Member (name)

o Estimated Cost

o Status

9 – Export to Excel

This functionality, when clicked, will automatically convert the claims that are currently

displayed in the claims dashboard to an .xlxs file with the use of the MS Excel spreadsheet

application.

10 – Last Update Date

This section pertains to the most recent date that each claim has been registered, modified,

its status changed, or adjudicated.


11 – Service Date

This section pertains to the date that each claim has been initially registered, which the user

from the providers’ end cannot modify.

12 – Reference #

This section pertains to the reference number of each claim as its unique identifier, which can

either be automatically generated by PULSE or via other modes of prior request/claims

submission or manually provided by the adjudicators that are entered and saved from

NEXtCARE’s or Emirates’ end.

Such numbers can be utilized by the providers to track and monitor their claims (for various

purposes, e.g. claims’ reconciliation, etc.) and as authorization codes during claims’

submissions for processing and settlement.

13 – Card No. of the member

If the member did not present a physical medical insurance card during his/her visit(s) and used

a different ID instead, a card number will still reflect in this section, as each and every

NEXtCARE, Allianz, or Emirates member has a corresponding card number in the system,

regardless whether or not a physical medical insurance card was issued to the member.

The member’s card number is required for claims’ processing and settlement, hence, such

should be taken note of by the providers during claims submissions.

14 – Family of Benefits (FOB)

This section pertains to the type of service that was selected by the user for each claim.

The types of service are as follows:

o Out-Patient

o In-Patient

o Chronic Out

o Dental

o Optical

15 – Member’s Name

This section also includes the payer’s name of the member’s policy.

16 – Estimated Cost

This section pertains to the total net cost of each claim (gross amount [minus] agreed

discount [minus] patient share).

17 – Page Navigation tool

18 – Claims’ Status

This section pertains to the current status of each claim.

The claims’ status which can only be visible in the claims dashboard are as follows:

o Auto-Authorized

o Pending for Precertification

o Pending for Provider Response

o Pending for Payer Response

o Pending for Beneficiary Response

o Authorized

o Declined

o Expired



The section of PULSE wherein the users from the providers will be able to verify whether or not a visiting member is eligible to avail of their facility’s services, whether or not a visiting member is eligible for a specific service type, to verify if the member’s insurance policy is still active/valid or otherwise, and also where the electronic claim form (eASOAP form) can only be obtained from (if the member is eligible).

The users from the providers may either use the member’s 16-character medical insurance card number, policy number, or any other valid ID numbers which the member presents, as long as it is linked to the member’s insurance policy with NEXtCARE or with Emirates, in order to verify the member’s eligibility.

All fields are required to be accomplished by the user, except those which are marked as optional.

8.1.1. Checking for a member’s eligibility to a provider via PULSE

FIGURE 22: ELIGIBILITY VERIFICATION BY 16-CHARACTER MEDICAL INSURANCE CARD NUMBER

1 2

4

3

5

8. Eligibility Checking (Verification)


FIGURE 23: ELIGIBILITY VERIFICATION BY POLICY NUMBER

FIGURE 24: ELIGIBILITY VERIFICATION BY OTHER ID TYPES

6

7

8

9

10

11

12


FIGURE 25: CHECKING FOR ELIGIBILITY FOR EMIRATES AIRLINE MEMBERS (PAYER MUST BE SPECIFICALLY

SELECTED AS “EMIRATES AIRLINE”, WHILE EITHER THE EMIRATES ID NO. OR THE PASSPORT NO. CAN BE USED)

FIGURE 26: ELIGIBILITY VERIFICATION SCREEN SERVICE TYPES (FAMILY OF BENEFITS)


Legend for figures 22-24

1 – Current selected source of information for eligibility verification

16-digit medical insurance card number.

2 – Service Date

The current system date and time (as per NEXtCARE’s servers), which cannot be manipulated

by the users from the providers’ end.

3 – Card Number

The card number must be entered completely (all 16 characters) without any spaces or

special characters. As the user types the card number in this field, it automatically hyphenates

for every 4 characters

This field is not case-sensitive, hence, the user can use upper or lowercase alphabets alone

or it can be combined.

4 – Types of Service (please refer to figure 26)

The selected service type will correspond to the specific benefit limit that will be utilized from

the member’s insurance policy. By selecting either one of such during eligibility verification, the

user will also be able to identify on whether or not a particular member’s insurance policy has

coverage for such service type.

The currently available types of service, applicable to healthcare providers, are as follows:

o Out-Patient

o In-Patient

o Chronic Out

o Dental

o Maternity

o Optical

o Psychiatry

5 – Check Eligibility confirmation button

By clicking this, the user will be able to identify on whether or not the visiting member is eligible

for their facility or for the selected service type.

If the member is eligible, the user will be able to print the electronic claim form (eASOAP form)

for the attending clinician to accomplish.


Policy number.

7 – Payer name

This field will only be required from the user if the source of information for eligibility verification

is either by the policy number or any other ID numbers other than the 16-digit medical

insurance card number issued by NEXtCARE.

8– Case/Policy number

9 – Member’s given name and family name

This field, as also specified in PULSE itself, is optional to be filled in with details by the user.


ID numbers from other sources (other than the medical insurance card issued by NEXtCARE).

11 – ID Types

The currently available types of identification documents to choose from are as follows:

o National ID (equivalent to the Emirates ID in the UAE)

o Pin #

o Passport

o Identity Card

o Social Security

o Military ID

o Driving License

o Others


o Work Permit

o Residency Card (Iqama)

12 – Other IDs’ no. field

The other types of ID numbers must be entered in this field (corresponding the selected ID

type).


8.1.2. Eligibility check results

FIGURE 27: ELIGIBILITY VERIFICATION RESULT FOR AN ELIGIBLE MEMBER (NEXtCARE MEMBER)

FIGURE 28: ELIGIBILITY VERIFICATION RESULT FOR AN ELIGIBLE MEMBER (EMIRATES MEMBER)

1

2 3 4

5

6

7

8


Legend for figure 27

1 – Eligibility result description (member’s name + selected service type + facility name)

Will only be visible if the entered member’s details appear as eligible.

2 – Create claim (please refer to figure 28)

Once this has been clicked, the user will be directed to the claim registration screen, without

having to re-enter any of the member’s personal and/or policy information.

3 – Print form (please refer to figures 29 to 31)

Clicking this will cause the electronic claim form (eASOAP form) to get downloaded.

This button is automatically disabled for Emirates members (not applicable).

4 – Reset

Clicking this will refresh the eligibility verification page with all the previously entered details

cleared out, in order to make way for a new claim entry.

5 – Coverage information

This indicates the currently selected service type in which the member is shown to be eligible

for.

6 – Member’s personal and basic insurance policy information

The payer ID of the insurer (payer) will also be displayed in this section, right beside the name

of the insurer itself (e.g. INS000/SP000/A000). Such is crucial for electronic claims submission,

especially for those providers which are submitting their claims via a different electronic claims’

platform (e.g. eClaimLink, Greenrain, etc.).

If a member has a VIP policy, an additional field will appear in-between the class and category

fields as VIP: Yes

7 – Service date



8 – Benefits highlight

Based on the user’s selected service type, specific services such as consultation,

laboratory, radiology, and pharmacy will either have the note covered (full coverage by the

payer) or the member’s share (deductible and/or coinsurance as per the member’s

insurance policy’s terms and conditions, which the provider has to collect from the member

itself) indicated with it.

For all Emirates members, the patient share will always have the value zero.

If the service type chronic out is selected by the user and the member’s insurance policy has

coverage for chronic conditions, but there is a stipulated waiting period for it, such will be

displayed in the chronic out section (e.g. waiting period for “x” months counting from the

“x” date).

Gatekeeper pertains to the protocol wherein members having such stipulated in their insurance

policies, are required to visit a gatekeeper physician, which are technically general

practitioners, wherein a written or an electronic referral (eReferral via PULSE) is made if ever

the member has to see a specialist/consultant physician. Hence, if there is a yes noted in

this particular field, then the member has an active gatekeeper protocol in his/her insurance

policy, which has to be enforced by the user from the provider’s end. This is only applicable for

NEXtCARE members.

The referral number field will have details in it if there is an active eReferral generated via

PULSE (only active for 7 days from its initial generation date). Such eReferral no. will be

required if a prior approval will be requested for a claim prescribed by a specialist/consultant

physician, via PULSE.

The billing field pertains to the specific coverage that the member has for the user’s selected

service type, particularly on how the claimed invoices will be refunded (by the provider and/or

the member), which can be direct billing and/or reimbursement.


8.1.3. Member Ineligibility Results

“This beneficiary is not eligible for (type of service) at (provider’s name)”

This will be indicated for visiting beneficiaries whose policy networks are not eligible for the

facility that is visited (e.g. RN-network policy is ineligible for direct billing services at a GN-

network facility).

This will also be indicated for visiting beneficiaries whose policies are not eligible for specific

service types (e.g. maternity, dental, etc.).

FIGURE 29: ELIGIBILITY VERIFICATION RESULT – INELIGIBLE (1)

“This beneficiary is invalid”

This will be indicated if the user enters the beneficiary’s required details (e.g. card no.)

incorrectly during eligibility verification.

This will also be indicated for visiting beneficiaries whose policies have either expired, canceled,

or is currently being renewed.



“This beneficiary is suspended”

This will be indicated if the member’s policy is currently blacklisted by the payer.



FIGURE 32: CLAIM REGISTRATION (FROM THE ELIGIBILITY VERIFICATION SCREEN)


FIGURE 33: NEXtCARE/ALLIANZ eASOAP FORM (OUT-PATIENT/IN-PATIENT/MATERNITY/PSYCHIATRY CLAIM

FORM)


FIGURE 34: NEXtCARE/ALLIANZ eASOAP FORM (DENTAL CLAIM FORM)


FIGURE 35: NEXtCARE/ALLIANZ eASOAP FORM (OPTICAL CLAIM FORM)



The section of PULSE wherein the users will be able to register their claims, which will either be automatically or manually adjudicated, and eventually either then be authorized or declined.

If claims were registered and were authorized via PULSE, it can also be submitted to the electronic post office for processing and settlement directly via the said portal as well, specifically for those providers which are electronically submitting their claims (a function that is currently only available for DHA and HAAD-based pharmacies in the UAE).

This section is comprised of 4 divisions, namely: member information fields (eligibility verification), medical information fields, services’ fields, and attachments (which must be accomplished sequentially).

FIGURE 36: CLAIM REGISTRATION SCREEN (AFTER CLICKING “CREATE NEW CLAIM” FROM THE MAIN MENU

SIDEBAR) – FOR NEXtCARE MEMBERS

1

2

9. CLAIMS REGISTRATION

(“CREATE CLAIM”)


FIGURE 37: ELIGIBILITY VERIFICATION IN THE CREATE CLAIM SCREEN (FOR EMIRATES MEMBERS)

FIGURE 38: MEDICAL INFORMATION SECTION (CLAIM REGISTRATION SCREEN)

4

3

7

5

6

8

9

10


FIGURE 39: PRIMARY DIAGNOSIS MENU (MEDICAL INFORMATION SECTION - CLAIM REGISTRATION SCREEN)

FIGURE 40: SECONDARY DIAGNOSES SCREEN (MEDICAL INFORMATION SECTION - CLAIM REGISTRATION SCREEN

11

12

13

14


FIGURE 41: ELIGIBILITY VERIFICATION FIELDS (CLAIM REGISTRATION SCREEN – MEMBER IS NOT ELIGIBLE)

FIGURE 42: ELIGIBILITY VERIFICATION FIELDS (CLAIM REGISTRATION SCREEN – MEMBER’S DETAILS ARE

INVALID)


FIGURE 43: FAMILY OF CAUSE – OP/IP/CHRONIC (MEDICAL INFORMATION SECTION - CLAIM REGISTRATION

SCREEN)

Legend for figures 36, 38, 40 (Eligibility Verification and Medical Information

sections – Claim Registration screen)

1 – Eligibility verification fields

The functionalities of these fields are exactly similar with the eligibility verification screen

(please refer to section 8).

The user will only be able to proceed in registering claims via PULSE if the member’s details

that are entered in these fields yield an eligible result (for the user’s facility and for the selected

service type) (please refer to figures 41 and 42).

In the card section, if the user is unable to enter the full 16-character medical insurance card

number, additional fields below it will be required (name and year of birth) in order to extract

further specific information for the eligibility verification (please refer to figure 42).

2 – Service date



3 – Physician field

The user may search physicians’ details in this field using either the name of the physician or

its medical license number

If the user chooses to change the currently selected physician’s details, the user just has to

enter a new one in the same field, and if such is available, it will automatically replace the

current one.

If the service type that is selected by the user is anything other than dental (in one of the

eligibility verification fields), all physicians with specializations relating to dentistry (general

dentists, orthodontists, etc.) will not be searchable.

4 – Consultation date

The user may manually type in the consultation date (default format is mm/dd/yyyy) or simply

just click the calendar icon and choose the date from it accordingly.

5 – Primary diagnosis field

The field which is readily visible on the claims registration screen is where the user can enter

the primary diagnosis, whether it is by its description/name or its equivalent ICD code.

As the user types in the field, a drop-down menu appears along with it, where the user can

select one from it accordingly (as per the physician’s findings).


If the user wants to change the current diagnosis in the field, the user just has to click the x

button and enter a new one.

6 – Family of cause (please refer to figure 40)

Clicking on the button will reveal a drop down menu for the user to select from, which should

correspond both to the service type selected by the user and the diagnosis(es) of the member.

7 – Cause

This field will only be unlocked if the service type selected by the user is maternity.

8 – ePrescription download tool

The user (usually from a pharmacy facility) will be able to download electronic prescriptions

uploaded by physicians to the DHPO with this tool, utilizing the member’s medical insurance

card number and the eRx number generated from the eClaimLink.

9 – eReferral download tool

This functionality’s development is still currently in progress.

10 – Secondary diagnosis link/tool

Clicking this will reveal the secondary diagnosis pop-up screen (please refer to figure 37).

The user will be able to add more diagnoses on top of the primary one with this functionality

(as secondary diagnoses).

Once the user confirms the entered details in the secondary diagnosis pop-up screen, it will not

be visible in the main claim registration screen, unless the secondary diagnosis button ( ) is

clicked again.

11 – Vital signs, last menstrual period, and chief complaint symptoms

These fields are not mandatory; however, the user can utilize such especially for complex or

high-cost claims, as supporting data.

12 – Secondary diagnosis field

The field wherein the user can enter additional diagnosis(es) (secondary), whether it is by

its description/name or its equivalent ICD code.

As the user types in this field, a drop-down menu appears along with it, where the user can

select one at a time from it accordingly (as per the physician’s findings).

13 – Diagnoses list

This is the section of the secondary diagnoses pop-up screen where the list of all the selected

diagnoses can be seen by the user (which is also specified as primary or secondary).

The onset date for each diagnosis can also be indicated by the user optionally.

In order to delete any of the selected secondary diagnosis, the user must click the trash bin

icon.

14 – “Ok” button

By clicking this, the user confirms the entered details in the secondary diagnosis pop-up screen.


FIGURE 41: ePRESCRIPTION/eRx DOWNLOAD TOOL (MEDICAL INFORMATION SECTION- CLAIM REGISTRATION

SCREEN

FIGURE 42: SERVICE ITEMS SECTION (CLAIM REGISTRATION SCREEN)

15 23 22 21

20 16 17 30

27

29 19 28

18

25 24

26

31


FIGURE 43: DRUG CALCULATOR (SERVICE ITEMS SECTION - CLAIM REGISTRATION SCREEN)

FIGURE 44: DENTAL SERVICES (SERVICE ITEMS SECTION - CLAIM REGISTRATION SCREEN)

32

33


FIGURE 45: UNIVERSAL TOOTH NUMBERING SYSTEM (AMERICAN SYSTEM)

34 35

36 37

38


FIGURE 46: MOST USED LABORATORY ITEMS (SERVICE ITEMS SECTION - CLAIM REGISTRATION SCREEN)

FIGURE 47: MOST USED RADIOLOGY ITEMS (SERVICE ITEMS SECTION - CLAIM REGISTRATION SCREEN)


FIGURE 48: ATTACHMENTS SECTION AND CLAIM REGISTRATION CONFIRMATON BUTTON (CLAIM REGISTRATION

SCREEN)

Legend for figures 42, 44-45, 48 (Service Items and Attachments sections –

Claim Registration screen)

15 – Item code field

The user will be able to search for any of their facility’s service items (those which are within

the agreed tariff) by entering service item codes (e.g. CPT, CDT, HCPCS, etc.) in this field.

A minimum of 3 characters must be entered in this field in order to extract search results.

The user must avoid entering spaces in this field as such search attempts will not yield any

results.

16 – Item description field

The user will be able to search for any of their facility’s service items (those which are within

the agreed tariff) by entering its description/label in this field.

A minimum of 3 characters must be entered in this field in order to extract search results.

The user must enter the description/label of the service items exactly the way it is as per the

agreed tariff, in order to extract accurate search results.

17 – Item code (requested service items list)

These fields are where the selected service items’ codes (e.g. CPT, CDT, HCPCS, etc.) are

indicated.

18 – Item description (requested service items list)

These fields are where the selected service items’ descriptions/labels are indicated.

39 40

42

47

45

41

43 44 46


19 – Service name (requested service items list)

These fields are where the selected service items’ service types (evaluation and

management, pharmacy and vaccinations, etc.) are indicated.

20 – Drug DD (requested service items list) – “Drug Daily Dosage”

These fields pertain to the drug intake frequency per day as prescribed by the physician to the

members.

This must only be utilized for pharmaceutical service items.

21 – Drug POT (requested service items list) – “Drug Period of Treatment”

These fields pertain to the total period of drug intake (in days) as prescribed by the physician

to the members.

This must only be utilized for pharmaceutical service items.

22 – Unit (requested service items list)

These fields are where the selected service items’ forms of packaging (e.g. blisters’ pack,

bottles, etc.) are indicated.

Clicking on either one of the contents in the unit fields of the selected service items’ list will

open the drug calculator pop-up screen (please refer to figure 43 in the previous pages).

Only pharmaceutical service items (drug items) have contents in these fields.

23 – Quantity (requested service items list)

The user will be able to specifically indicate the quantity of each of the prescribed service items

in these fields, which will affect the calculation of the cost for every item.

24 – Unit price (requested service items list)

These fields are where the selected service items’ cost per quantity is indicated, as per the

agreed tariff (which means that each unit price is already applied with an agreed discount).

These fields cannot be manipulated by the users from the providers’ end.

25 – Total price (requested service items list)

These fields are where the selected service items’ total costs are indicated (quantity x unit

price).

These fields cannot be manipulated by the users from the providers’ end.

26 – Delete (requested service items list)

These trash bin icons, if clicked by the user, will delete any of the selected service items.

27 – Number of items/Price

The number of items indicates the total number of selected service items (not calculating

the quantity per item) by the user.

The price indicates the total cost of the claim (consolidated costs of all the selected service

items).

28 – Estimated cost

This field is where the user can manually indicate the total estimated cost of the requested

claim, which is only optional, as the total cost of the claim is automatically calculated as per

the list of items that are selected by the user.

If some of the service items are not found by the user while searching for such, either by its

code or description, then its costs can be manually calculated by the user and then add it to the

costs of the service items that are existing in PULSE.

29 – Invoice number

The invoice numbers of each claim are automatically generated from NEXtCARE’s or

Emirates’ end once it has been registered via PULSE, which will reflect in this field.

30 – Most commonly used laboratory and radiology items (please refer to figures 46 and 47).

Clicking on either one of these will open a pop-up screen which either has a consolidated list

of all the most commonly requested laboratory or radiologic service items.

If the user ticks any of the boxes beside each laboratory of radiologic service item in these lists,

such items will automatically add to the list of selected service items in the main claims

registration screen.


These lists do not necessarily mean that each provider in NEXtCARE’s or Emirates’ network

has an agreed price for every service item in it. Hence, if a user ticks certain items in either one

of these lists and their facility does not have agreed prices for such, it will still add up to the list

of selected service items in the main claims registration screen, but its unit price will appear as

zero.

31 – Drug calculator tool (requested service items list)

Clicking on either one of the contents in the unit fields of the selected service items’ list will

open the drug calculator pop-up screen (please refer to figure 43).

While utilizing the drug calculator, the user will be able to specifically indicate the prescribed

number/pieces of drugs per intake (unit per frequency), frequency of drug intake

(frequency value), frequency type (per day, per hour, when needed, etc.), and the period

of treatment (in days). Doing so will adjust the quantity of the corresponding service items

that the drug calculator has been utilized for.

32 – Requested service items list (dental services)

The user can manually search for dental service items via the main claim registration screen

(same with searching for other types of service items) while also manually entering the specific

tooth number for each item or utilize the dental treatments tool instead.

33 – Dental treatments tool (requested service items list)

This will only be available if the user selects dental as the service type for the claim that is

being registered.

Clicking this will open the dental items pop-up screen.

34 – “Press and hold for tooth multiselection” prompt

This prompt is an instruction that the user can make multiple selections in the teeth chart in one

go without having to do it separately.

35 – Universal (dental) numbering system

This chart is a dental notation system for associating information to a specific tooth.

The user will be able select the appropriate teeth where the dental practitioner has prescribed

certain dental services for, by clicking on each tooth in the diagram, and then selecting from

either one of the listed services on the right hand side of the screen. Multiple teeth can be

selected by clicking and holding on one tooth for a couple of seconds and then releasing it to

reveal check boxes on all the teeth for the user to just tick in order to make a selection.

36 – Most commonly prescribed dental services list

Clicking on each of the headers per types of dental service will reveal specific items related to

it for the user to select from (once a tooth/set of teeth has been selected from the dental chart).

If the specific dental service is not included in this list, the user can just manually search for

such in the main claim registration screen (services section) by its code or description instead

and then typing in the corresponding tooth number for it.

37 – Requested dental service items list

Other than the items selected by the user from the most commonly prescribed dental

services list, the dental services which were manually searched and selected from the main

claim registration screen will also be included in this list.

Teeth numbers which have been manually indicated by the user on the main claim registration

screen will not be marked in the dental chart.

38 – Close button

Clicking this will close the dental items pop-up screen.

39 – Notes field/free text field (optional functionality)

This field is where the user can manually enter any additional relevant information for the claim

which cannot be indicated in any of the other fields or sections of the claim registration screen.

This is also where the user must indicate the description/label of any documents that will be

attached for any claims (otherwise, any attachments without any descriptions will not be

uploaded with any claims).


40 – Attachment upload tool (optional functionality)

Clicking this will direct the user to his/her own computer’s files (wherever PULSE is being

accessed with) in order for the user to select any from it and attach it with the claim via PULSE.

The user may attach most image formats (JPEG, BMP, etc.) and/or various types of

documents (e.g. MS excel documents, MS word documents, etc.), except for videos.

41 – Post note confirmation tool (optional functionality)

Clicking this will post any notes or upload any attachments (with descriptions/labels) with

the claim.

42 – File type (posted notes and uploaded attachments list)

These fields are where the posted notes’ and/or uploaded attachments’ file formats (e.g. CMT

for plain text notes, PDF, JPEG, etc.) are indicated.

43 – File name (posted notes and uploaded attachments list)

These fields are where the uploaded attachments’ file names are indicated.

Plain text notes that are posted will not have any details in these fields.

44 – File size (posted notes and uploaded attachments list)

These fields are where the posted notes’ and/or uploaded attachments’ file size are indicated

(in kilobytes).

45 – Notes (posted notes and/or uploaded attachments list)

These fields are where the posted notes’ and/or uploaded attachments’ descriptions/labels

are indicated (those which have been manually entered and posted by the user in the notes

field).

46 – Delete (posted notes and/or uploaded attachments list)

If clicked by the user, will delete any of the selected posted notes or uploaded documents.

47 – Create claim confirmation tool

Clicking this will result in the claim being registered (sent to NEXtCARE or Emirates) as a prior

request, which will be subjected to adjudication, either automatically or manually, and

eventually either then be authorized, declined, or sent back with a query from NEXtCARE

or Emirates.

The prompt below (figure 49) will appear as soon as this button is clicked, where the user can

either click confirm to send the claim for registration or otherwise, click cancel.

If the user confirms, a claim reference ID will be automatically generated for the registered

claim (please refer to figure 50). The claim reference ID is hyperlinked to the actual claim

screen; hence, if such is clicked by the user, it will direct the user to the main screen of the

registered claim (view claim screen). Otherwise, if ok was clicked, it will direct the user to

the claims dashboard instead.

FIGURE 49: CLAIM REGISTRATION CONFIRMATION PROMPT


FIGURE 50: CLAIM REGISTRATION CONFIRMATION PROMPT

FIGURE 51: VIEW CLAIM SCREEN (FOR NEXtCARE/ALLIANZ MEMBERS)


FIGURE 52: VIEW CLAIM SCREEN (FOR EMIRATES MEMBERS)


FIGURE 53: VIEW CLAIM SCREEN (FOR ALL MEMBERS)

48

49

52 51

50

53

54

55

57

56

58

59

60

61 62

66

63

64 65

67

68

69 70 71 72


FIGURE 54: PRECERT TERMS & CONDITIONS SECTION (VIEW CLAIM SCREEN)

FIGURE 55: ATTACHMENTS SECTION (VIEW CLAIM SCREEN)

73

74

75

77 78

76


Legend for figures 53 - 55 (View Claim screen)

48 – “Medical Report and Bill to NEXtCARE” prompt

This indicates that the claim has successfully been registered to NEXtCARE (but does not

necessarily mean that it has been submitted for processing and settlement).

This prompt will appear as “Please follow the regular claim submission procedure” on

claims for Emirates claims.

49 – Claim status

Can either be any of the following (when viewed from the claims dashboard screen):

o Auto-Authorized

o Authorized

o Declined

o Pending for Precertification

o Pending for Provider Response

o Pending for Payer Response

o Pending for Beneficiary Response

o Expired

50 – Print Auto-Authorization/Authorization/Pending Form (please refer to figures 55 - 57)

Clicking this will allow the user to obtain an electronic copy of such forms which have an

itemized services’ list (in contrast to the traditional authorization or pending forms).

51 – Confirm Service Delivery

This functionality is similar to dispense, that is currently only applicable to HAAD and DHA-

based pharmacies in the UAE (those which submits their claims electronically), which

allows users to directly submit their claims to NEXtCARE or to Emirates for processing and

settlement via PULSE. However, this is specifically designed for non-pharmacy providers,

but is currently only applicable to Dry Docks Clinic (in Dubai).

52 – Modify

This functionality will allow users to directly modify their claims as needed, whether it is because

there is a query from NEXtCARE or Emirates that requires feedback from the provider or just

because the provider needs to change something from the claim.

This is currently only applicable to HAAD and DHA-based providers (all types) in the UAE

(those which submits their claims electronically).

Only the information on the services section of the claims registration screen can be modified

by the user.

Modifying claims will automatically cancel the previous claim reference ID, creates an exact

copy of its contents, where the user can do the allowed modifications, and a new reference ID

will be generated after the user sends the same claim again for registration.

53 – Void

Clicking this will cancel the entire claim (the user must indicate his/her reason in the text field

provided, before doing so). Canceled claims have the status of not used which cannot be

tracked in the claims dashboard screen.

54 – Claim reference ID/No.

55 – Medical information

Contains all the related details as entered by the user during the claims registration process.

56– Length of stay (LOS)

This is only applicable for in-patient claims (the service type selected must be in-patient in

order for the user to indicate values to this field during claims registration). A minimum value

0.5 (half day admission) can be entered in this field.

57 – Secondary diagnosis tool

Clicking this will open the secondary diagnosis pop-up screen.

58 – Services (header)

Clicking this will open the selected/requested service items list.


59 – Attachments

Clicking this will open the attachments screen, wherein if there are any notes posted or

uploaded attachments during claims registration will be seen.

60 – Precert Terms & Conditions

Clicking this will open the screen where the adjudication notes from NEXtCARE or Emirates

are indicated, whether the claims have been authorized, declined, or pended (queries from

NEXtCARE or from Emirates).

61 – Requested Estimated Cost and Estimate Cost

Requested estimated cost

o The value in this field corresponds to the total requested cost (discounted cost) of the

claim without any applied deductibles and/or copayments yet.

Estimated cost

o The value in this field corresponds to the overall cost of the claim, inclusive of any

applicable deductibles and/or copayments.

62 – Invoice Number

If the user indicated details in this field during claims registration, it will also be indicated here

as well. However, if the user is from a facility that submits claims electronically through a

regulator’s electronic post office (DHPO and HAAD PO in the UAE), whatever details that the

user manually indicates in this field during claims registration will be overridden with an auto-

generated invoice no. after the claims have been submitted for processing.

63 – Currency

This is the default monetary currency of the provider based on the territory (country) it is located

at.

64 – Viewable service items navigator tool

The user will be able to select, from values of 10-100, as to how many service items will be

displayed onscreen.

65 – Search

The user will be able to specifically search for any of the requested services items within the

claim, utilizing the service codes, item description, service type, or even the price values as

well. This can be especially useful if the requested service items are numerous.

66 – Requested service items list

Other than checking the actual status (authorized or pending) of the claims, the user must

also take note of the "qty approved" section of the services list in order to confirm whether or

not all the requested services have been authorized (it must match the "qty claimed",

otherwise, such services are either partially authorized or declined).

The patient share section is where any applicable deductibles or copayments are indicated,

which are deducted from the total approved values (discounted amounts), and will result to

the net claimed and payer share values (in most cases, especially if the member’s benefit

limits are still within its coverage).

For all Emirates members, the patient share will always have the value zero.

The package unit section only applies to pharmaceutical items, where the packaging forms

(e.g. bottle, blister pack, etc.) of such items are indicated.

The adjustment reason section is where any applicable rejection reasons are indicated for

each service item that is requested within every claim.

67 – Page navigation tool

This will enable to user to navigate through multiple pages (if applicable) of the requested

service item list.

68 – Export to Excel

This functionality, when clicked, will automatically convert the requested service items list,

within the claim, to an .xlxs file with the use of the MS Excel spreadsheet application.


69 – Net Claimed

The value indicated in this field corresponds to the total approved amount (based on the

agreed tariff with the provider) inclusive of any applicable patient shares (deductibles

and/or copayments). This should be the same value as the one in the payer share field, as

this amount will be the one paid by the payer to the provider.

70 – Total Approved

The value indicated in this field corresponds to the total approved amount alone, not

inclusive of any applicable patient shared (deductibles and/or copayments).

71 – Patient Share

The value indicated in this field corresponds to any applicable deductibles and/or

copayments set by the payers to its respective policies.

72 – Payer Share

The value indicated in this field corresponds to the total approved amount (based on the

agreed tariff with the provider) inclusive of any applicable patient shares (deductibles

and/or copayments). This should be the same value as the one in the net claimed field, as

this amount will be the one paid by the payer to the provider.

73 – “Decision” section (Pre-cert Terms & Conditions)

If the claim has been auto-authorized, authorized (through manual adjudication), pended

(due to queries or for manual adjudication), or expired the corresponding status for such will

be indicated in this field.

However, if the claim has been auto-declined, an automated denial reason will be indicated

in this field, based on the members’ policy and the pre-set system rules. But if a claim has been

manually declined, the adjudicator from NEXtCARE or Emirates will still have to choose from

any of the default denial reasons that will be applicable to the adjudicated claim which will also

be indicated in this field.

74 – Precertification note field

This is where any adjudication notes from NEXtCARE or Emirates are indicated, whether

the claims have been authorized (by manual adjudication), declined (by manual

adjudication), or pended (queries from NEXtCARE or Emirates).

Auto-adjudicated claims will not have any details in this field.

75 – Attachments/Notes list

This is where any of the posted notes or uploaded attachments is listed within every claim.

The users will also be able to download any authorization or declined forms in this section

for claims which have been manually adjudicated.

76 – Note field (free text)

Just like in the claims registration screen, this is where users can post additional notes (as

plain texts or descriptions for additional attachments) for claims which have the status of

authorized, auto-authorized, or pending for provider response (users can respond to

queries from NEXtCARE or Emirates with this functionality).

However, for those providers wherein the modify functionality is enabled for their PULSE

accounts, this section will be disabled in the view claim screen.

77 – Attachment upload tool

Just like in the claims registration screen, this is where users can upload additional

attachments, for claims which have the status of authorized, auto-authorized, or pending

for provider response (users can respond to queries from NEXtCARE or Emirates with this

functionality). The user must indicate a description/label for any attachments in the note field

prior to uploading such.

However, for those providers wherein the modify functionality is enabled for their PULSE

accounts, this section will be disabled in the view claim screen.

78 – Post note/upload attachment confirmation

Clicking this will upload the note or attachment with the claim and the status of the claim will

change to pending for precertification.


Ticking the press enter to send box is optional, and will only allow the user to press enter

on the keyboard in order to post notes or attach documents instead of clicking the post button.


FIGURE 56: NEXtCARE/ALLIANZ AUTO-AUTHORIZED ADJUDICATION FORM (AUTO-GENERATED)


FIGURE 57: NEXtCARE/ALLIANZ AUTHORIZED ADJUDICATION FORM (AUTO-GENERATED)


FIGURE 58: NEXtCARE/ALLIANZ PENDING ADJUDICATION FORM (AUTO-GENERATED)


FIGURE 59: EMIRATES PENDING ADJUDICATION FORM (AUTO-GENERATED)


FIGURE 60: EMIRATES AUTHORIZED ADJUDICATION FORM (AUTO-GENERATED)


FIGURE 61: EMIRATES AUTO-AUTHORIZED ADJUDICATION FORM (AUTO-GENERATED)


9.2. eAuthorizations and ePrescriptions (DHPO), and Claim Modification and Submission via PULSE (DHPO and HAAD PO)

In order for the user to obtain eAuthorizations (prior approvals for claims which have passed

through the DHPO, which is a mandate for all Dubai-based providers), download

ePrescriptions from the DHPO, and perform direct claim modifications and claim

submissions via PULSE, the user must connect their respective facility’s regulator

electronic post office credentials (eClaimLink account’s username and password for DHA

and Shafafiya account’s username and password for HAAD) to PULSE.

The user must first log in to their PULSE account, access settings and then post office

credentials (as seen in figure 62 below), which will display the post office credentials screen.

In such screen, the user must first tick the checkbox and then enter their electronic post

office credentials in the corresponding fields, before clicking ok to confirm (which, if

successful, will display a prompt as seen in the screenshot below).

Both the post office username and password fields in PULSE are case-sensitive; hence, the

user must enter such details exactly as it is when used to access the actual post office

platforms (DHA’s eClaimLink/HAAD PO’s Shafafiya portal), in order for the linking of the

PULSE account to the respective regulator’s post office to be successful.

The providers must ensure that their facility license nos. are in sync with NEXtCARE’s or

Emirates’ systems, in order to successfully link their electronic post office credentials to

their PULSE accounts. Hence, every time that such expires and then gets renewed into a

different one, the providers must immediately notify NEXtCARE’s medical provider

management department or the Emirates medical benefits team of such matter.

FIGURE 62: POST OFFICE CREDENTIALS SCREEN


eAuthorization (all Dubai-based facility types) and Claim Modification (all

facilities submitting eClaims via the DHPO and HAAD – pharmacies only)

The eAuthorization initiative is one of DHA’s mandates for Dubai-based healthcare providers

since the beginning of the year 2017, wherein all prior requests and prior authorizations for claims

on direct billing basis of all provider types are required to pass through the DHPO (between the

providers and the payers/TPAs), which is a functionality that PULSE offers.

As aforementioned, in order to enable this functionality in PULSE, the provider’s electronic post

office credentials must be successfully linked to their PULSE account.

The user can then proceed in registering claims via PULSE as usual, however after registration,

the user is given an additional option to modify the service items section of the claims as needed

(but only if the claims have the status of either authorized, auto-authorized, or pending for

provider’s response).

Other than claim modification, another feature that is added once the user successfully links the

electronic post office credentials to PULSE is the claim TAT. The claim TAT allows the provider to

track the progress of the claims in the post office level and to identify whether or not the claim

encountered errors in the process, as manifested by the presence of a retry link, which if clicked

by the user, will display a link where the error file (.xlxs file format) can be downloaded from

that contains the exact details of the error’s cause or it will simply display an error prompt message

(please refer to figure 65).

Any errors encountered in the claim TAT must immediately be reported to the PULSE Support or

the Emirates Medical Benefits Support helpline for further assistance/advice.

FIGURE 63: “MODIFY” AND “CLAIM TAT” FEATURES (VIEW CLAIM SCREEN)


FIGURE 64: CLAIM TAT FIELDS – PRE-REQUISITE DATE/TIME STAMPS MET FOR “eAUTHORIZATIONS” AND “CLAIM

SUBMISSIONS” (VIEW CLAIM SCREEN)

FIGURE 65: SAMPLE CLAIM TAT ERROR


Claim TAT fields relevant to eAuthorizations:

Request Submit Date: the date and time when the prior request was sent to the post office

from the provider.

Request Download Date: the date and time when the prior request was downloaded from

the post office by NEXtCARE.

Auth. Submit Date: the date and time when NEXtCARE sends the prior authorization to the

post office.

Auth. Download Date: the date and time when the provider downloads the prior

authorization from the post office.

Cancel Submit Date: time and date when either the provider or NEXtCARE cancels the claim

which is sent to the post office.

Cancel Download Date: the time and date when the provider’s or NEXtCARE’s cancelation

has been confirmed from the post office level and is sent back to the party who initiated the

cancelation.

If the any of the relevant date/time stamps does not automatically appear in the respective fields,

the user may click on the refresh button in the claim TAT section to make it so.

Once the Claim TAT fields request submit date, request download date, auth. submit date, and

auth. download date have been filled in with date/time stamps, such would indicate that the claim

has went through the entire cycle of eAuthorization.

Should there be any queries from NEXtCARE to the providers with their claims, wherein the status

of such claims will display as pending for provider’s response, the providers can respond back

by utilizing the modify functionality.

Modifying claims will automatically cancel the previous claim reference ID, creates an exact copy

of all its contents, where the user can do the allowed modifications (service items) and/or attach

required documentations, and a new claim reference ID will be generated after the user sends

the same claim again for registration.

FIGURE 66: SAMPLE AUTHORIZED CLAIM FOR MODIFICATION (C0007253650/2)


FIGURE 67: SAMPLE CLAIM BEING MODIFIED (C0007253650/2)

FIGURE 68: NEW CLAIM REFERENCE ID GENERATED AFTER CLAIM MODIFICATION AND RE-REGISTRATION (C0007253650/3)


FIGURE 69: MODIFIED CLAIM WITH THE NEW CLAIM REFERENCE ID (C0007253650/3)


Claim Submission (DHA and HAAD pharmacies)

This functionality allows applicable PULSE accounts to submit claims which were registered via

PULSE to the respective electronic post offices for processing and settlement. This functionality

appears in PULSE as dispense for pharmacies and confirm service delivery for non-pharmacy

facilities (currently only available for 1 Dubai-based provider).

As with enabling eAuthorizations and claim modification, the provider’s electronic post office

credentials must be linked to their PULSE account in order to enable claim submission via PULSE.

All the same procedures and rules for a general claim registration and eAuthorization must be

applied in order to meet the conditions for claim submissions via PULSE, the only difference is that

in the claim TAT, 3 additional fields must also be filled in with date/time stamps to ensure the

success of the claim submission, which are as follows:

Claim Submission Submit Date: the date and time when the claim was uploaded to the post

office from the provider (for processing and final settlement).

Claim Submission Download Date: the date and time when the claim submission was

downloaded from the post office by NEXtCARE.

Claim Dispense Date: the date and time when the provider clicked the dispense (or confirm

service delivery for non-pharmacy facilities) button. Having a date/time stamp in this field

alone does not necessarily mean that the claim has been successfully submitted to the

electronic post office for processing, as the first 2 aforementioned fields must have date/time

stamps along with it as well.

Any errors encountered in the claim TAT must immediately be reported to the PULSE Support

helpline for further assistance and/or advice, and must not be delayed to avoid instances of late

submissions or claim expiries.


FIGURE 70: SAMPLE CLAIM READY FOR SUBMISSION (DISPENSE)

FIGURE 71: CLAIM TAT AFTER A SUCCESSFUL CLAIM SUBMISSION


Once the dispensed claims have been received at NEXtCARE’s or Emirates’ end and are batched

for processing (this also applies for claims which have not been submitted via other means,

whether it was done electronically or manually), batch info will be available in the view claim

screen for the provider’s reference (as seen in figure 68).

FIGURE 72: BATCH INFO (VIEW CLAIM SCREEN)

ePrescription (DHA – pharmacies)

ePrescriptions are electronic drug prescriptions generated via the DHPO by clinicians with

registered accounts to access the eClaimLink’s eRx Clinician System, which must be

downloaded by pharmacies while utilizing their eClaimLink accounts or any other electronic

platforms that are linked to their eClaimLink accounts (e.g. PULSE).

All prescriptions dispensed within Dubai must be in electronic form, as per one of DHA’s mandate

(2018), hence, an eRx no. is required to be created by the prescribing facility and to be downloaded

by the pharmacy (otherwise, any pharmacy claims without such will be automatically rejected).

In order for the provider to successfully download ePrescriptions from the DHPO via PULSE, as

with enabling eAuthorizations and claims’ submissions, the provider’s PULSE account must be

successfully linked to their eClaimLink account as well.

Once the PULSE account has been linked to the eClaimLink account, the provider must navigate

to the claim registration screen, as if the user will be creating a fresh claim, however, instead of

entering all the relevant details, the following steps below must be followed (figures 73-75):


FIGURE 73: ePRESCRIPTION DOWNLOAD TOOL (CLAIM REGISTRATION SCREEN)

FIGURE 74: ePRESCRIPTION DOWNLOAD TOOL (POP-UP WINDOW)


FIGURE 75: DOWNLOADED ePRESCRIPTION FROM THE DHPO

Once the ePrescription has been downloaded, none of the details in it can be modified except for

the quantity, which can only be modified less than the prescribed one or left originally as it is,

prior to registering it as a claim.

The generated claim reference ID from registered ePrescriptions will be different from the claims

that are manually registered via PULSE; instead of “C000…,” it will be “EA000…”

After registration and if the claim has been authorized, the provider may then dispense it for

processing (as long as the Claim TAT condition is met) or modify it as necessitated.

9.3. Gatekeeper Protocol (eReferral Procedure)

Gatekeeper pertains to the protocol in which members having such stipulated in their insurance policies, are required to visit gatekeeper physicians, which are technically only general practitioners, wherein a written or an electronic referral (eReferral via PULSE) is made if ever the member has to be further assessed by a specialist/consultant physician.

The provider can verify if the member has the gatekeeper protocol in his/her policy by utilizing the eligibility verification functionality of PULSE, wherein a yes must be indicated in the gatekeeper field.

This is currently only applicable to NEXtCARE members (not for Emirates’).

Steps on how to obtain eReferrals via PULSE (figures 69-71):

The PULSE user must navigate to the claim registration screen and create a claim while

utilizing a general practitioner as the physician (gatekeeper clinician). Once the create

claim button is clicked, the user will be prompted to choose whether there is a need for a


referral or none. In order to create an eReferral, the user must select confirm and register the

claim as usual.

FIGURE 76: eREFERRAL CREATION (CLAIM REGISTRATION SCREEN)

Once the claim has been registered, other than the claim reference ID, the eReferral number will

also be generated along with it. Note that such number will only be visible from this pop-up window

and in the eligibility checking screen (while utilizing the same member’s details for such).

An eReferral number can be used for an indefinite number of times within its 7-day validity (from

the time of its generation), regardless of the specialty of the attending physician that the member

will be visiting.

FIGURE 77: eREFERRAL NUMBER GENERATED (AFTER REGISTERING A CLAIM)

JOHN DOE

INS003 – TEST PAYER01

2872-185D-0CCD-2118


FIGURE 78: eREFERRAL NUMBER AS DISPLAYED IN THE ELIGIBILITY CHECKING SCREEN

JOHN DOE is Eligible for Out-Patient at PULSE PROVIDER

JOHN DOE


2872-185D-0CCD-2118


Steps on how to utilize eReferral numbers:

The same steps of a regular claim registration must be followed if an eReferral number is to be

used in order to proceed in registering a claim for a gatekeeper member visiting a

specialist/consultant physician via PULSE. Once the eReferral number is accepted, the user

should be able to proceed in registering the claim as usual.

FIGURE 79: eREFERRAL NUMBER BEING REQUIRED PRIOR TO REGISTERING THE CLAIM (CLAIM REGISTRATION

SCREEN)

For members of Emirates Airlines whose policies require referrals, instead of the Gatekeeper field in the eligibility verification screen indicated as yes (for NEXtCARE members only), it will be indicated in the field as specified in the screenshot below.

Note that the gatekeeper protocol (as discussed in the previous section of this guide) will not be applicable for members of Emirates Airlines whose policies require referrals.

For any inquiries or assistance on any applicable referral processes for EK members, it must be directed to the Emirates Medical Benefit support team (for their contact details, please refer to section 4, page 7 of this guide)

JOHN DOE


2872-185D-0CCD-2118


FIGURE 80: ELIGIBILITY VERIFICATION SCREEN FOR AN EMIRATES AIRLINE MEMBER WITH REFERRAL


1.1 A guarantee of payment (GOP) is issued by for special cases to network healthcare providers for the

purpose of financial settlement of claims for services availed by insured members who are holding

policies that are out of the providers’ network coverage (e.g. RN-network policy member going to a GN-

network provider).

With PULSE, providers will be able to request for GOPs, particularly for emergency and in-patient

cases, which is applicable to all providers who offer and render such services.

10.1. Creation, Submission, & Modification of GOP Requests

Access PULSE with the link https://pulse-uae.tatsh.com/Login2.aspx?s=2.

10.1.1. Verify the Member’s Eligibility

o Enter any of the agreed member ID numbers such as the 16-character medical insurance card number, policy number, or the government issued National ID/Emirates ID number etc. in its respective sections.

o Select “Emergency Room Services” or “In-Patient” in the “Type” field.

o Click on “Check Eligibility” to display the result.

If the result shows that the member is eligible, proceed as per the usual process.

(for more details please refer to section 8, page 26 of this user guide).

If the result shows that the member is not eligible with the message, “<Member's

Name> is Not Eligible for <Type of service> at <Provider Name>. Please submit a

GOP request.", then, click the “Create GOP Screen button, as seen in the

screenshot below.

FIGURE 81: ELGIBILITY VERIFICATION RESULT (PRE-REQUISITE FOR A GOP REQUEST)

10. GUARANTEE OF PAYMENT (GOP)

ISSUANCE VIA PULSE



o The "Create GOP request" screen is the new label of the already existing screen called

"Claim Registration” (as seen in the screenshot below).

o The member information will automatically be filled on the left of the form if the “Create

GOP request” screen is accessed from the Eligibility Result Screen.

o The member information will have to be filled in the Member information section on the left

of the form, if the “Claim Registration” Screen is accessed by clicking the “Create Claim”

link in the main menu bar.

In this case, the member information is to be filled the same as is done in the

“Eligibility Verification” screen.

The result and the message displayed will be the same as seen in the Eligibility

Result Screen as shown below (Fig. 82) and clicking on the “Create GOP Request”

button located under the message will display the "Create GOP request" screen.

(Fig. 83).

FIGURE 82: ELGIBILITY CHECKING FOR GOP REQUESTS VIA THE CREATE CLAIM SCREEN


FIGURE 83: CREATE GOP CLAIM SCREEN

10.1.2. Creation of a GOP Request

o Once the member information is filled, proceed with filling the rest of the form.

Providers who use the DHPO to submit their claims, while entering an Emergency

room service GOP request, must ensure to use the DSL code 61.08 –

Consultation by physician at Emergency Room in the Service item grid section

while registering the GOP request in PULSE. This code is to be also mentioned in

all related documents and notes if any are being submitted along with the request

(Fig. 84).


FIGURE 84: SERVICE ITEM GRID (CREATE CLAIM SCREEN – GOP REQUEST)

Providers who use other means to submit their claims, while entering an

Emergency Room service request, must ensure to use the relevant service code

in the Service item grid section while registering the GOP request in PULSE. This

code is to be also mentioned in all related documents and notes if any are being

submitted along with the request.

In the case of In-patient requests proceed to enter the service items in the the

service item grid of relevant and attach all notes and documents as per usual

protocol.

o Once the form is filled, and the "Create GOP Request" button is clicked the message "Are

you sure you want to send the GOP request form?" is displayed in a pop up window. (Fig.

85).

FIGURE 85: CREATE GOP REQUEST CONFIRMATION PROMPT


Clicking on “Cancel” will close the pop up window and will revert to the filled form.

Clicking on "Confirm" will display a pop up window with the message "Registered

Successfully. GOP Request has been successfully Registered. Reference ID is

C000...." (Fig. 86). The reference ID generated may be used to track the status of

the request.

Clicking on the reference ID link will open to the registered GOP Request with the

status “Pending for Pre-Certification”. (Fig. 87).

Click on “OK” to be routed to the Claims Dashboard screen and show the registered

GOP request in the “Pending Claims” section with the status “Pending for Pre-

certification”. (Fig. 88).

FIGURE 86: GOP REQUEST CONFIRMATION MESSAGE

FIGURE 87: VIEW CLAIM SCREEN FOR A GOP REQUEST (“PENDING FOR PRECERTIFICATION”)


FIGURE 88: VIEW OF THE GOP REQUEST ON THE CLAIM DASHBOARD SCREEN

10.1.3. Modifying a GOP Request

o GOP claims with statuses “GOP Issued” or “Pending for Provider Response” can be

modified if the user’s account has the “Post Office Credentials” Setting activated in PULSE,

in which case the following steps apply (please refer to section 9.2., page 67 for further

details on linking PULSE to the DHPO or the HAAD PO).

Search for and click on the GOP Claim to view it (This can be done in both the

Claims Dashboard and Search Screens).

Click on the “Modify GOP Request” button to cancel the previous request and to

automatically open to a copy of the same. Scroll down to the Service Item Section

of the View Claim Screen and modify the Service Items, post notes and attach

documents as required (Fig. 89).

Once complete, proceed to click on the “Create GOP Request” button to register

the modified request (Fig. 90).

It is important to note that the claim reference number will remain the same but the

digit after the / will change depending on the number of times the claim was

modified. E.g. C000….../1 will change to C000……/2 and so on.

o For providers where the active “Post Office Credentials” setting is not required, they may

proceed to request for any changes via the “Post note” and “Attached Documents” section

of the claim.


FIGURE 89. MODIFY GOP REQUEST BUTTON

FIGURE 90. COPY OF THE ORIGINAL GOP REQUEST AFTER CLICKING ON “MODIFY GOP REQUEST”


10.2. Tracking/Searching GOP Requests via PULSE

10.2.1. Verify the Member’s Eligibility

o Any registered GOP request or claim can be searched for using the reference ID.

Simply navigate to the Claims dashboard, click on the Tab of the section (Pending,

Pre-Certified) you wish to view and its details will be shown. (refer to Fig 88); or,

Select “Search” from the main menu bar and you may use the various parameters

available in the “Claim Search” section to retrieve the exact information being

queried.

o Various tools such as filters, search fields and even exporting the information to excel are

available to aid in the search and tracking process.

o The following are the main messages that are shown within the GOP claim and on the

Dashboard as well, to know the status of a GOP request:

The initial status of a successfully registered GOP request will always be “Pending

for Pre-certification”.

In cases where NEXtCARE’s Precertification Team has requested for additional

information, the status of the Registered GOP request will reflect as "Pending for

Provider Response" (Fig. 88)

In cases where the request is approved, the status of the Registered GOP request

will read as “GOP Issued” (Fig. 92). A copy of the Authorization will be available for

download in the “Attached Documents” section.

In cases where the request is declined, the status of the Registered GOP request

will read as “Declined” (Fig. 93).

FIGURE 91. VIEW CLAIM SCREEN FOR A GOP REQUEST (“PENDING FOR PROVIDER RESPONSE”)


FIGURE 92. VIEW CLAIM SCREEN FOR AN AUHORIZED GOP REQUEST (“GOP ISSUED”)

FIGURE 93. VIEW CLAIM SCREEN FOR A REJECTED GOP REQUEST (“DECLINED”)


o Please note that registering a GOP request in PULSE is only for the purpose of attaining

pre-certification on the same. The claim submission process will remain the same as per

contractually agreed.


1.2

11.1. Claim Search

The section of the “search” functionality wherein the users will be able to browse and monitor any

of their claims, regardless of its status (e.g. processed or not, active or expired, settled or otherwise,

etc.) and its mode of submission or where the approvals were obtained from, as long as it has been

successfully received by NEXtCARE or Emirates; or were manually entered and saved from

NEXtCARE’s or Emirates’ end.

Reports can also be generated from this section of PULSE, for claims’ reconciliation purposes and

for the providers to identify the details of any remittance advice or other forms of claims’ settlements

that they receive.

It is comprised of the basic and advanced search modes (please refer to figures 76 and 77).

Users will be able to search with claim information or with the member’s information while using the

basic search mode.

Users will be able to search with the payment information or with the claim batch information while

using the advanced search mode.

If the provider receives a payee advice from NEXtCARE (which is usually by email from the

bank) which serves as a notification of claims that have been settled by the payers, the user

can utilize the reference no. indicated in such as a search parameter in order to extract

reports/details for such settlements (the user has to enter such in the bank reference field

(under the payment information section) while using the advanced search mode).

The payment date search parameter (under the payment order information section)

corresponds to the reception date of the claims’ remittances from the corresponding payers

by the providers.

The maximum returned rows corresponds to the number of claims which are expected to be in the

results of every claims inquiry search. By default, it is 200 claims, which the user can freely modify

depending on the search parameters that will be indicated in the other fields.

The details available in the search results via basic search will be less compared to advanced

search (thus, the fewer column fields).

Once the user has finished entering all the necessary search parameters, search will be clicked in

order to extract search results, which will appear just below the search parameter fields (please

refer to figures 78-80).

Once the search results have displayed, the user will be able to convert such into an excel sheet

report, by clicking the export to excel button on the upper-right hand corner of the search results

page.

11. SEARCH


FIGURE 94: BASIC SEARCH MODE (SEARCH SCREEN)

FIGURE 95: ADVANCED SEARCH MODE (SEARCH SCREEN)


FIGURE 96: BASIC SEARCH RESULTS (SEARCH SCREEN)

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER

JOHN

DOE

JOHN

DOE

JOHN

DOE

JOHN

DOE

TEST

PAYER

TEST

PAYER

TEST

PAYER

TEST

PAYER


FIGURES 97-98: ADVANCED SEARCH RESULTS (SEARCH SCREEN)

11.2. Batch Search

The section of the “search” functionality wherein the users will be able to browse and monitor claims

which have already been batched after a successful submission, whether by electronic (eClaims)

or manual (paper invoices) submissions. Claim batching is a requisite for processing and eventual

settlement of claims.

Batching of all electronically submitted claims are automated, once such are downloaded from the

respective electronic post offices (DHPO or HAAD PO) by NEXtCARE or Emirates. Such batches

have also automatically generated batch reference nos. which can be utilized to search for claims

in this functionality.

Batching of all manually submitted claims are done manually (submission of paper invoices and

related documentations) and no batch reference nos. are generated.

Claim submission dates can also be utilized to search for claims in this functionality, however, only

those claims which have already been batched will appear in the results, regardless whether such

are auto-batched (with batch reference nos.) or manually batched (without batch reference nos.).

Each batch which appears in the search results can be expanded in order for the user to see the

claims that are in it.

An excel format report of the search results can also be downloaded from this screen (by clicking

the “export to excel” button).


FIGURE 99: BATCH SEARCH (SEARCH SCREEN)

FIGURE 100: BATCH SEARCH RESULTS (SEARCH SCREEN)

JOHN DOE

JOHN DOE

JOHN DOE

JOHN DOE

JOHN DOE

JOHN DOE


FIGURE 101: CLAIMS SUMMARY (SEARCH SCREEN)

11.3. Claims Summary

The section of “search” wherein providers, whose PULSE accounts are connected to its respective

electronic post office accounts (DHPO or HAAD PO), will be able to monitor their claims on whether

or not such have been submitted (dispensed) successfully to the post office and received by

NEXtCARE or Emirates for processing and settlement.

The user simply has to input the desired dates in its corresponding fields when searching with this

functionality and clicking execute query in order to extract results. An excel format report can also

be downloaded from this search.



12.2. Claims not yet delivered

12.2.1. Claims Batches

This screen allows you to search for all the claims that are already in a batch.

12. CLAIMS DELIVERY


Available search criteria: Batch #, Label (you may search here by payer name), Reference, Period,

status, created from and to.

Once one or more criteria are selected, click on , the page will scroll down automatically

to display all claims delivered to NEXtCARE and having batch numbers:

12.2.2. Claims not delivered

Shows all claims not delivered to NEXtCARE.

Just enter “Till transaction date” and click on


All claims are selected by default for easier access.

Click on to create batch for all selected claims. Summary of which is shown as

follows:

Also at this level, you may click anywhere within the line to view the claim details or if the claim never

took place, you may delete it by clicking on

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12.3. Upload Batch

Electronic bills are uploaded in PULSE in the “Upload Batch” screen.

The excel/xml file containing the claim information that was extracted from the provider systems

can be uploaded into PULSE by either dragging the file into the “Import ̀ Claims e-Bills Data” section

or by clicking in that section and selecting the file from the user’s system.

Clicking on the “Import Data” button will display the message “Your file is under process. You can

check the upload history here.”

Clicking on the “here” link will route the user to the “e-Bills History” screen which is also accessible

via the main menu taskbar.


12.4. e-Bills History

The e-Bills History screen can be used to enter different search parameters to search for and view

the claims that were uploaded as shown in the below screenshot.

If there is an error encountered with the file uploaded the error description will be shown to indicate

to the user what needs to be rectified in the file to re upload it.

If there is no error encountered all the claims inside the file will be populated in the grid below.


The section of PULSE wherein various circulars and other provider-specific notifications can be

communicated from NEXtCARE to the users from the providers, which can be in a form of plain

texts or with attached related documents. The PULSE user, though, will be unable to utilize this

functionality to respond to any of the received messages or send new ones.

Clicking on this will direct the user to the “Inbox” page.

INBOX SCREEN

Legend (Inbox screen)

1 – Messages list

The messages are arranged with the latest ones appearing at the bottom of the list.

2 – Date and time when the message was sent from the sender

3 – Message subject line from the sender

4 – Body of the message which contains the actual message of the sender (there may or

may not be anything indicated in this field).

5 – Attachment(s)

6 – Mark as Read button

7 – Delete button

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3

4

6

5

7

13. INBOX


14.1. Change Password

After logging in PULSE, the user navigates through the main menu sidebar, which is at the left side

of the screen, and clicks on settings, and the change password screen will be displayed (please

refer to figure 15).


again.

14.2. Upload logo

This functionality will allow users to upload an image file (.jpeg, .png, etc.) which corresponds their

facilities’ logo that will be displayed every time they log into PULSE.


again.

UPLOAD LOGO SCREEN

14. SETTINGS


The user will just have to click the middle part of the screen (with the note “drag files here or click

to upload”) which will direct the user to his/her own computer’s files (wherever PULSE is being

accessed with) in order for the user to select the appropriate image file.

Once the image file has been selected, the user then has to click upload.

Once the image file/logo has been successfully uploaded, the user will be able to see such after

the succeeding logins to PULSE.

UPOAD LOGO SCREEN (2)


UPLOAD LOGO SCREEN (3)

SUCCESSFUL LOGO UPLOAD PROMPT (UPLOAD LOGO SCREEN)


MAIN MENU SIDEBAR (WITH THE PROVIDER’S LOGO)

14.3. Post Office Credentials

This functionality is currently only applicable for HAAD or DHA-based facilities in the UAE, wherein

the mode of claims’ submission is done electronically via the respective regulator’s electronic post

office.

The user will just have to enter the facility-specific credentials (username and password) used to

access the respective regulator’s post office’s website/application (eClaimLink or Shafafiya) in the

designated fields on this screen (PULSE), which are highly case-sensitive fields. Furthermore, the

user would have to tick the check box prior to clicking the save button to confirm.


14.4. Manage Users

This functionality will allow certain users to manage all the registered user IDs to access the

provider’s PULSE account. This is by means of restricting or expanding the users’ accesses to the

functionalities of PULSE, by activating or inactivating user IDs, and also by resetting the passwords

of user IDs (to the default “0000”).

Only the user with the role of healthcare provider administrator (which is as per what NEXCARE or

Emirates has designated for such users), which should be someone in the provider with authority

over the staff/specific teams (e.g. facility owner, manager, etc.).

USERS SECTION (MANAGE USERS SCREEN)

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2

3 4 8 7 9 6 5


ROLES SECTION (MANAGE USERS SCREEN)

Legend (Users and Roles – Manage Users Screen)

1 – Users tab

Clicking this will reveal all the registered user IDs for the logged in provider in PULSE, whether

it is active or inactive (either suspended from the provider’s end or from NEXtCARE/Emirates).

2 – Search field

The users will be able to specifically search for any of the available user IDs by using either

one of the following information:

o Name of the User

o Username

o User Role

o Job Position

o Phone No.

o Email ID

3 – Full Name

Name of the owner of the user ID.

4 – Username

User IDs used to access PULSE.

5 – User Role

These roles are being designated from NEXtCARE’s or Emirates’ end, which determines the

extent of the accessibility of the PULSE users.

10 11

17 16 15 14 13

12


6 – Status

Active – user ID can still be used to access PULSE.

Inactive - user ID cannot be used to access PULSE.

If the user clicks on active for a particular user ID, it will deactivate such, while clicking the

inactive button will activate it.

7 – Job Position/Phone No./Email

Details indicated in these fields are the ones which are registered by the users with NEXtCARE.

8 – Action

Clicking reset password will automatically reset the selected user IDs password back to the

default (0000).

9 – Page navigation tool

10 – Roles tab

Clicking this will reveal all the registered user IDs for the logged in provider in PULSE,

categorized in its designated user roles (which are only setup from NEXtCARE’s or Emirates’

end).

11 – Healthcare Provider Administrator (User Role)

Users assigned with this user role will have full access to all the features of PULSE, and is the

one with access to the manage users functionality.

12 – User IDs listed under each category of user roles

13 – Healthcare Provider Accountant (User Role)

Users assigned with this user role will only have access to the following features of PULSE:

o Claims Dashboard (although the view claim screen for any claims cannot be

opened)

o Claims Delivery

o Search (claim searching can be executed and reports can be downloaded, however,

the view claim screen for any claims cannot be opened)

o Inbox

o Settings (only the change password functionality can be accessed)

o Help

14 – Healthcare Provider ER (User Role)


o Claims Dashboard

o Eligibility Checking (only “Emergency Room Services” will be available as the

“service type”)

o Create Claim (only “Emergency Room Services” will be available as the “service

type” – eligibility verification section)

o Search

o Inbox


o Help

15 – Healthcare Provider Out-Patient (User Role)


o Claims Dashboard

o Eligibility Checking (“In-Patient” will not be available as “service type”)

o Create Claim (“In-Patient” will not be available as “service type” – eligibility

verification section )

o Search

o Inbox


o Help

16 – Healthcare Provider In-Patient (User Role)



o Claims Dashboard

o Eligibility Checking (only “In-Patient” will be available as the “service type”)

o Create Claim (only “In-Patient” will be available as the “service type” – eligibility

verification section)

o Search

o Inbox


o Help

17 –Batch Upload Officer (User Role)


o Claims Dashboard (although the view claim screen for any claims cannot be

opened)

o Inbox


o Help


The section of PULSE wherein the users from the providers can access an electronic copy of the

said portal’s user guide and a list of the FAQs (Frequently Asked Questions) as well.

Clicking on user guide or FAQs will open the PDF file of the respective option that is selected.

15. HELP