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    • 25 SEP 14
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    Guidelines for the Early Detection of Cancer

    Breast cancer Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health Clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and over Women should know how their breasts normally look and feel

Frequently Asked Questions For Insured Life

Who is pentacare medical services?

Pentacare is a TPA ( Third party Administrator) specializing in health insurance services to manage claims in a very effective and efficient manner.

Is Pentacare an Insurance company?

No, we are a TPA which works in alliance with Insurance companies and other payers as an administrative support for claims management.

What role does Pentacare (TPA) play?

We deal in providing complete Health Insurance management and Third Party Administration services to Insurers and other Payers of Healthcare.

How do I use my health insurance card?

You need to present your Pentacare Health Insurance card every time you visit a health services provider (hospital/clinic / Pharmacy) within the network assigned before availing any services in order to qualify for direct billing.

What is direct billing?

You show your card to the provider listed in your network and only pay the deductible written on the card along with co payment (if applicable) for availing the medical services without paying for full cost out of your pocket.

What is co-payment (co –pay)?

It is a portion of medical expenses incurred, usually a fixed percentage written on the card itself, which you have to pay out of your own pocket.

Can I visit a non network provider?

Yes you can, however it would not be on direct billing. You have to pay for the services  in full and file a reimbursement claim for eligible expenses. Also,Check your insurance policy  if it allows for reimbursement in a non- network provider.

How is a pre existing condition defined?

Any Beneficiary health condition known to the Beneficiary and/or to the Contractholder that exhibited symptoms or was a consequence of Injury or Illness for which medical, Surgical and/or pharmaceutical Treatment, medical diagnosis or other advice was provided prior to the Beneficiary’s Enrollment Date.

How do I apply for reimbursement claim?

You have to fill the reimbursement form which is signed and stamped by your physician and you.

How do I get the reimbursement form?

You can contact your HR or you can download it from our website

Frequently Asked Questions For Providers

How many networks are available with Pentacare?

There are five networks available with Pentacare they are Penta Plus, Penta 1, Penta 2, Penta 3 and Penta Eco.

How do I know if a Healthcare facility is on Pentacare Network?

Pentacare Network members are updated on a monthly basis with the list of providers included in their networks. Check with your point of contact with regards to your policy (HR/insurance company/broker as applicable) for the list of providers where you are eligible.

Am I eligible to visit any provider on Pentacare Network?

Please refer to the Pentacare Medical Provider list, which is the tabulation of eligible categories to said provider.

How do I find the address, location of a facility within the network?

Please visit the “Medical Provider” section on the Pentacare Website to get further details of your preferred facility.

How can I be a part of Pentacare Network?

To become a part of Pentacare Network, you have to forward your letter of interest on Pentacare empanelment to Network Team at network@pentacare.net. Please note that empanelment is at the sole discretion of Pentacare wherein the feedback evaluation of your application will be communicated in writing – subsequent to the evaluation process.

How do I report a complaint against a facility?

We strongly recommend that all complaints are reported to Pentacare 24/7 HELPLINE at the point of incident. Our HELPLINE agent will resolve minor issues within the scope where possible and guide you on the procedure in forwarding a written complaint.

Frequently Asked Questions PBM / E Claims

What is PBM / e Rx?

In contemplation with DHA mandate dated on 30th December 2013, all medical providers should request electronic approvals from payer/TPA (Pentacare) for all prescriptions (either paper or electronic form). The portal of this electronic system is PBM (http:// www.pbmlink.com)

How to activate PBM system?

The medical providers who are in network list of Pentacare need to send email request for activation of PBM at network@pentacare.net with license specifications (DHA/HAAD/MOH)

How many days it will take for activation of PBM?

It will take 3-5 workings days upon receipt of the email request of activation.

How we do submit claims through PBM?

• The providers who are using non-integrated system and processing through all transactions through PBM portal http: // www.pbmlink.com// are entitled for real time claims submission through system. Automated PBM approval code will be generated and the system will process these claims for submissions to Pentacare.

• The providers who are using integrated system are entitled for claims submissions at end of month in form of e claims to Pentacare

How can we resubmit fully /partially rejected services through e claims?

Upon receipt of Remittance advice, you can re-upload the rejected services with the requested details. For any further assistance, you can contact us at doctors@pentacare.net

What are Payer Id‘s for e claims processing?

DHA /Dubai Providers

Pentacare’s ID/ Receivers ID

TPA013 – PENTA CARE MEDICAL SERVICES LLC

Payer’s ID: For payer Id’s kindly contact us on network@pentacare.net

HAAD/ Abu Dhabi & Al Ain Providers

C008 – PENTA CARE MEDICAL SERVICES LLC

Payer’s ID: For payer Id’s kindly contact us on network@pentacare.net

What are e claim / Electronic claims billing?

E claim is a statement from health care provider presented to insurance company /TPA for evaluation and settlement of services through electronic portal. Electronic claims billing is the process by which a health care provider electronically submits a bill, or claims, to a Payer /TPA (Pentacare) for rendering medical services.

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