Download Flu - Treatment and Prevention

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