Page 7 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

4.3.3 HEALTH, WELLNESS, OCCUPATIONAL, AND SAFETY COMPLIANCE............................................ 79

4.3.4 UTILISATION REVIEW .................................................................................................................. 80
TUTORIAL .................................................................................................................................................... 82

INTRODUCTION ........................................................................................................................................... 83

5.1 MEDICAL AND HEALTH CLAIMS PROCEDURES ................................................................................... 83
5.1.1 DEALING WITH CLAIMS ARISING UNDER MEDICAL AND HEALTH INSURANCE POLICY 85

5.1.2 MANAGED-CARE ORGANISATIONS ............................................................................................ 87
5.2 PRE-AUTHORISATION ......................................................................................................................... 92

5.2.1 MEANING OF PRE-AUTHORISATION .......................................................................................... 93
5.2.2 PROCESS AND IMPACT OF PRE-AUTHORISATION CLAIMS ......................................................... 93

5.3 SCHEME MANAGEMENT ..................................................................................................................... 94
5.3.1 BASIC PRINCIPLES OF SCHEME MANAGEMENT AND ADMINISTRATION ................................... 95

5.4 TRANSFERRING BUSINESS .................................................................................................................. 96
5.4.1 BUSINESS TRANSFERS BETWEEN INSURERS .............................................................................. 96

5.4.2 OPTIONS AVAILABLE TO THE NEW INSURER ............................................................................. 96

5.4.3 CHANGE OF INSURER ................................................................................................................ 97
5.5 CONTRIBUTION, RECOVERIES, AND CLAIMS MANAGEMENT ........................................................... 97

5.6 THIRD-PARTY ADMINISTRATION IN THE CLAIMS MANAGEMENT .................................................... 98
5.6.1 BENEFITS AND CHALLENGES OF OUTSOURCING CLAIMS MANAGEMENT ................................ 99

5.6.2 RESPONSIBILITY OF THE INSURANCE COMPANY IN OUTSOURCING .......................................... 99
TUTORIAL .................................................................................................................................................. 101

INTRODUCTION ......................................................................................................................................... 102

6.1 DETERMINE THE APPLICATION OF LEGISLATION IN MHI BUSINESS ............................................... 103
6.1.1 FINANCIAL SERVICE ACT 2013 ................................................................................................ 103

6.1.2 GUIDELINES ON PRODUCT TRANSPARENCY AND DISCLOSURE ............................................. 104
6.1.3 PERSONAL DATA PROTECTION ACT 2010 .............................................................................. 105

6.1.4 ACCESS TO MEDICAL REPORTS ACT 1988; (UK) ..................................................................... 107
6.1.5 PRIVATE HEALTH CARE SERVICES AND FACILITY ACT 2006 ................................................... 108

6.2 FIGURE OUT THE MAIN FUNCTIONS OF FINANCIAL MEDIATION BUREAU ..................................... 108
6.2.1 ROLES AND GUIDELINES OF FINANCIAL MEDIATION BUREAU .............................................. 108

TUTORIAL .................................................................................................................................................. 110
7.1 ANALYZE THE BUYERS OF PRIVATE MEDICAL INSURANCE ............................................................... 111

6 | P a g e