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Rule Category: Medical Ref: No: 2011-MN-0011 ` Version Control: Version No.4.0 Effective Date: March 2011 Revision Date: August 2015 Flu - Treatment and Prevention Adjudication Rule Table of content Abstract Scope Adjudication Policy Page 1 Page 2 Page 2 Adjudication examples Page 2 Denial codes Page 2 Appendices Page 3 Approved by: Daman Abstract Responsible: Medical Strategy & Development Department For Members Flu is an acute respiratory infection caused by influenza virus that is usually selflimiting. Flu can cause mild to severe illness. Symptoms are more severe than those of cold and come on abruptly. Daman covers medically justifiable treatment of flu for all health insurance plans administered by Daman subjected to policy terms and conditions. Daman coverage of the flu vaccine (for prevention of flu) will be limited to those plans with the specific benefit, subject to policy terms and conditions. For Medical Professionals Flu is a viral disease and antibiotics are not used to treat the disease. Hence, Daman will not cover antibiotics for the treatment of flu. Daman covers medically justifiable treatment of flu (including Antipyretics/analgesics, Decongestant, antihistamine or combination) for all health insurance plans administered by Daman subject to policy terms and conditions. Daman coverage of the flu vaccine will be limited to those plans with the specific benefit, subject to policy terms and conditions. Related Adjudication Rules: None Disclaimer By accessing these Daman Adjudication Rules (the “AR”), you acknowledge that you have read and understood the terms of use set out in the disclaimer below: The information contained in this AR is intended to outline the procedures of adjudication of medical claims as applied by the National Health Insurance Company – Daman PJSC (hereinafter “Daman”). The AR is not intended to be comprehensive, should not be used as treatment guidelines and should only be used for the purpose of reference or guidance for adjudication procedures and shall not be construed as conclusive. Daman in no way interferes with the treatment of patient and will not bear any responsibility for treatment decisions interpreted through Daman AR. Treatment of patient is and remains at all times the sole responsibility of the treating Healthcare Provider. This AR does not grant any rights or impose obligations on Daman. The AR and all of the information it contains are provided "as is" without warranties of any kind, whether express or implied which are hereby expressly disclaimed. Under no circumstances will Daman be liable to any person or business entity for any direct, indirect, special, incidental, consequential, or other damages arising out of any use of, access to, or inability to use or access to, or reliance on this AR, including but without limitation to, any loss of profits, business interruption, or loss of programs or information, even if Daman has been specifically advised of the possibility of such damages. Daman also disclaims all liability for any material contained in other websites linked to Daman website. This AR is subject to the laws, decrees, circulars and regulations of Abu Dhabi and UAE. Any information provided herein is general and is not intended to replace or supersede any laws or regulations related to the AR as enforced in the UAE issued by any governmental entity or regulatory authority, or any other written document governing the relationship between Daman and its contracting parties. This AR is developed by Daman and is the property of Daman and may not be copied, reproduced, distributed or displayed by any third party without Daman’s express written consent. This AR incorporates the Current Procedural Terminology and Current Dental Terminology (CPT® and CDT®, which is a registered trademark of the American Medical Association (“AMA”), and the American Dental Association (“ADA”) respectively), and the CPT and CDT codes and descriptions belong to the AMA. Daman reserves the right to modify, alter, amend or obsolete the AR at any time by providing one month prior notice. National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550) Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 1 of 3 Flu - Treatment and Prevention Scope Adjudication Examples This guideline is to explain the policy of Daman on the coverage of the treatment and prevention of flu except the cases identified as epidemic or pandemic. Example 1 Question: A 5 year old child, holding basic plan was diagnosed with flu (ICD 9 code 487.1 as principle diagnosis). The doctor prescribed antibiotics for this child. Flu is an acute respiratory infection caused by influenza viruses that is usually self-limiting. Answer: The treatment will not be covered for this child. Antibiotics have no medical justification. Flu can cause mild to severe illness. Symptoms are more severe than those of colds and come on abruptly. Example 2 Question: A 65 year old male, holding basic plan was diagnosed with flu (ICD 9 code 487.1). After the treatment, the doctor prescribed seasonal flu vaccine for him. Adjudication Policy Eligibility / Coverage Criteria Answer: The vaccine will not be covered for this patient. When vaccination for flu is claimed for plans without the coverage for the same, it will be rejected. 1. Flu treatment Daman covers medically justifiable treatment of flu for all health insurance plans administered by Daman subjected to policy terms and conditions. Denial codes Daman covers the following treatment for flu infection which includes: Antipyretics/analgesics Decongestant, antihistamine or combination Code MNEC-004 2. Flu prevention Daman coverage of the flu vaccine will be limited to those health insurance plans with the specific benefit, subject to policy terms and conditions. Code Description Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities NCOV-003 Service(s)is (are) not covered CLAI-012 Submission not compliant with contractual agreement between provider & payer Requirements for Coverage ICD and CPT codes must be coded to the highest level of specificity. Appendices A. References Non-Coverage 1. American Lung Association (http://www.lungusa.org/lungdisease/influenza/in-depth-resources/coldand-flu-guidelines.html) 1. Flu treatment For Visitors plan the coverage is subject to policy terms and conditions. As the cause of flu is viral, antibiotics will not be covered by Daman. 2. American Academy of Pediatrics (http://aapnews.aappublications.org/cgi/co ntent/full/30/9/8) 2. Flu prevention is not covered for those health insurance plans that do not have the benefit of the coverage. 3. BMJ (http://www.bmj.com/content/308/6940/1 341.extract) 4. HAAD Preventive Standards Payment and Coding Rules Please apply HAAD payment rules and regulations and relevant coding manuals for ICD, CPT, etc. National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550) Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 2 of 3 Flu - Treatment and Prevention B. Revision History Date 01-07-13 15-07-14 Change V2.0: New template 1. 2. 3. V 4.0 Disclaimer updated as per system requirements Restored original effective date National Health Insurance Company – Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550) Doc Ctrl No.: TEMP/MSD-008 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 3 of 3