Health Care Insurance and Health Care Benefits Management Services
Integrated Solutions of Medical Claims Handling, and Medical Insurance Risk Assessment and Monitoring.

Medical Insurance has been available in the Saudi market for over 10 years and is now the major source of non-life premium income in the Saudi market.

Products offered by insurance companies tend to focus on traditional benefits and scopes of coverage. As per the Council for Cooperative Health Insurance's requirements, insurance companies in the Saudi market must offer clients Inpatient (including Day Patient) coverage, Outpatient/Ambulatory coverage providing cover for Laboratory tests, MRI and X-ray tests, Out Patient procedures, etc... Companies must also offer cover for Chronic Diseases, Specific Dental Treatments as well as Optical Aids.

TCS handles claims management of its clients for all medical insurance benefits offered in the Saudi market, on either a direct billing or reimbursement basis through the utilization of an advanced I.T. solution for the logging of received claims and invoices from providers.

Using automated provider price recognition and tracking, along with automated coverage rules, our team of experienced auditors review all incoming claims to determine both medical appropriateness of supplies used and medical procedures applied and also in conjunction with our system, ensure that the prices applied are in keeping with the contracted prices at the provider.

In this way, TCS helps control fraud and abuse and allows costs to be contained within reasonable and predictable boundaries. All this is in addition to activities to assist clients in developing new product offerings and strategies, Medical Insurance Risk Assessment, and Risk Monitoring.

Technical Management and Advice
It's not always all about results, but they do matter. Your business depends on your ability to consistently generate good results. To do that, you need the tools to make smart and fast decisions. If you operate in health insurance, smart decisions need smart management. This is where TCS can help. We provide system and knowledge based tools and personalized decision making assistance for all medical-related aspects of Technical Management. In keeping with this, TCS offers underwriting consulting services.

In particular, TCS offers guidance in terms of policy compliance with CCHI regulations. In addition to the creation & monitoring of underwriting structures, practices, and procedures, implementation of underwriting & performance tracking measures.

Be it assessing the risk factors of an individual's state of health on application, monitoring an insured's claims over the year to project future claims behavior or setting limits and conditions upon renewal, TCS can provide advice and support through its experienced technical staff. Technical Management and Advice service is not recommended to be selected without prior selection of Claim Handling service.

Preferred Providers Network Set-up and Management
Choice - quality of medical care - standards of accommodation - are factors you consider when choosing the providers for your offered networks. costs of the factors must be weighed and balanced against the benefits.

Your choice of network will affect the frequency and cost of claims your business experiences. TCS will help you weigh these costs and make these choices. we maintain excellent relationships with providers locally in saudi arabia and beyond (worldwide) and continuously monitor. Developments in terms of costs, care levels and availability. we pass this knowledge on to you, aiding you in making expert, cost effective choices.

Taking into account such factors as the geographical spread of your beneficiaries, the expectations of your clients for standards of available care providers and your target cost base, TCS can help you optimize your network set-up and composition to develop networks that best meet the needs of your business.

Also, as our client, you can access and choose to contract with all our affiliated providers, or to create targeted networks of select providers as per your needs. in all cases, TCS will advise and assist you in contract negotiation and maintenance, communication with providers and generally in maintaining a positive relationship with your healthcare providers.

Claim Handling

Call Center and Approvals Unit - Call reception and handling

The Call Centre and Approvals Unit can handle a variety of functions on your behalf, including:

•    Receipt of queries and complaints. Whether it be questions on what is covered by their policy or complaints and other issues, TCS's call centre receives, logs, and reports all such communication on behalf of our clients.
•    Advice on process for claiming. Disturbed health can be a time of heightened stress and frustration. You need to know that at such times your clients are well taken care of. That is why our call center staff go out of their way to facilitate the process of claiming. We are on hand to explain to your clients, in a professional and friendly manner, the steps they must go through during the process. We can help arrange and schedule their treatment, assist them in selecting a provider for treatment, organize with our Branch Medical Officers for quick and easy admission, assist with the organization of follow up treatment, etc...
•    Communications conduit. The Approvals Unit acts as a central conduit between all departments of TCS, clients, your internal staff and providers. Approvals Unit is the point of contact for all requests for admission approval from clients, providers or others. Our physicians in the Approvals Unit are fully qualified to make rapid decisions on eligibility for cover, either independently or in conjunction with a senior officer and can quickly advise patients of decisions on approval or otherwise.

TCS's Call Center is available 24 hours a day, 7 days a week, on the following numbers: 9 2001 4001

Admission Control
Over time, behavior changes, people come to expect more and claims become more frequent. You need a market-consistent approach to determine which claims should be covered, and which should be declined. Through its rigorous Admission Control procedures, TCS helps you monitor, maintain and improve your claim experience by ensuring that only valid, justifiable and reasonable claims are approved by providers. Our skilled Approval Officers (physicians), in coordination with our Call Centre staff, and aided by our system-based controls and procedures, review all submissions for approval of treatment. Under admission control, TCS also handles all communication with providers for issuance and delivery to providers of our ‘P.A.S.S.’ form to ensure patients are admitted by providers quickly and with minimum disruption or discomfort. Based on stringent but fair decision making processes, TCS can help you reduce the incidence of claims arising as a result of fraud, non-disclosure and moral hazard. TCS can assist with the management and control of potential Significantly Large (Jumbo) claims through rigorous control starting as early as the time of admission all the way to case by case negotiations with providers to ensure that the best possible prices are offered.

Medical Decision Making
Claim control does not end at the approval stage. Correct monitoring of ongoing treatment modalities and care strategies is required to safeguard that your clients are receiving appropriate treatment without exposing you to unnecessary or avoidable costs. TCS’s team of Claim Officers, with support from our panel of in-house and consulting physicians and our Branch Medical Officers, regularly monitor treatment of patients once admitted to hospitals. In case the result of the monitoring is unjustifiably excessive or inappropriate to the presented condition, our team intercede on your behalf and on behalf of your client. Our daily monitoring, observations, decisions and the general medical situation of the patient are available to you for viewing online via our dedicated monitoring tools.

Invoice Entry and Claim Auditing
TCS utilizes an advanced I.T. solution for the logging of received claims and invoices from providers.

Using automated provider price recognition and tracking, along with automated coverage rules, our team of experienced auditors review all incoming claims to determine both medical appropriateness of supplies used and medical procedures applied and also, in conjunction with our system, ensure that the prices applied are in line with your contracted prices at the provider.

In this way, TCS helps you control fraud and abuse and allows costs to be contained within reasonable and predictable boundaries.

Reinsurance Reporting
Over time, business needs may change. But one need stays constant: trust. You need to know that your providers and partners will be there when you need them most. Nowhere is this more important than in your reinsurance relationships. TCS provides you with the reporting and associated services needed to satisfy the most stringent reinsurance reporting requirements in a manner that fosters trust and cooperation between you and your reinsurers.

TCS can assist in the preparation of monthly, quarterly and annual reporting to reinsurers with a variety of bordereau and other relevant statistical reports available for delivery to your reinsurers. Reports and data inquiries can be made available directly to your reinsurers online if you so require. In addition, TCS can grant your reinsurers access to a variety of informational tools, including policy and insured overviews, claims overviews and online monitoring tools at your request.

Insurance I.T. Solutions and Integration
TCS operates a dedicated, comprehensive I.T. solution for the management of all aspects of medical underwriting, claims and reporting in addition to other adjunct services.

Our clients may choose to utilize our system directly, or via an online connection. The system is used for underwriting and policy issuance, taking advantage of our advanced pricing and product creation tools to create flexible, detailed plans with multiple layers of controls, fully integrated with rule-driven, system based management.

Our clients may also access our range of online and offline reporting, reinsurance and monitoring tools to gain insight into all aspects of their business that we service.

Product Design
Using the knowledge of both the market and your portfolio in particular, we can assist in the design and creation of new products for your use. This is done with the help of our team's depth of experiences, which range from medical practice, I.T, insurance and actuarial backgrounds, and who can introduce a multifaceted approach to product design, enhancing your own product development activities. Taking into account factors including your target market, desired level of competitiveness and the range and scope of benefits, and using our knowledge of the current environment and observed market trends, we can help you put in place products which are competitive, robust and resilient to change.

Actuarial Reporting
TCS offers its clients access to our Actuarial Reporting service, through which clients will receive targeted and in-depth actuarial reports. These reports will be prepared upon request but may include:

•   Portfolio reviews
•   Performance and profitability analysis by product
•   In depth analysis of risk profiles, portfolio sensitivity and claim behavior
•   Projection of trends and overall experience
•   Actuarial recommendations for alterations to strategy, product design and process

Pricing Review
This service is offered only in conjunction with the Actuarial Reporting service. TCS will assign technical and actuarial resources to analyze pricing, in conjunction with and based upon actuarial portfolio and product reviews. Our staff, working in unison with our clients, review pricing results and where necessary, advise pricing and market strategies per product. In tandem, and based on our clients' targets for profitability and market penetration, TCS will consult our clients for the necessary revision of prices.

General Insurance Consultancies
Policy wordings need to be correct, forms and documents need to be appropriate, concise and understandable. The client's medical access cards should show all relevant information. The beneficiary and claims guidelines should rely to your clients in a way that reduces possible confusion, misunderstanding or conflict.

TCS can assist in these technical matters and more. We offer you the benefits of our unique and extensive experience in health insurance and management to monitor underwriting activities and advise you of any identified abnormalities or weaknesses.