Comprehensive Medical Billing, Clinical Workflow, and Administrative Operations Guide

Billing Core Procedures and Diagnostic Guidelines

• General Billing Actions:

  • Execute Bill Recalculate at the start of billing processes.
  • Select Invoice total orders to capture all pending items.
  • Utilize Cashier all orders (the last paper icon) for processing.
  • Check for diagnosis codes: F codes are acceptable if secondary; O codes (pregnancy) and Z codes (screenings) are also used.

• Insurance Icon/Status Management:

  • Red dot / Yellow icon: Inform the patient that tests must be sent for insurance approval.
  • Approve: Change the status to "Approved action."
  • Partially approve: Change to "Partially approve patient to pay" (indicates a copayment is required).
  • Rejected: Change to "Rejected patient will pay."
  • Query: Send an email to the doctor for clarification.
  • Approval not required: Delete the approval code before billing.

• Mandatory Testing Determinations (Self-Pay vs. Approval):

  • Vitamin Tests (Usually Self-Pay unless specific diagnosis provided):
    • Vitamin D ($25-OH \text{ Vitamin D}$)
    • Vitamin B12
    • Folate (Vitamin B9)
    • Full vitamin panels (Always self-pay)
  • Hormone Tests:
    • TSH (Thyroid-stimulating hormone): Do not send if no symptoms; send for approval if symptoms exist.
    • Free T3 / Free T4: Send for approval if TSH is abnormal or symptoms are present.
    • Testosterone, Estrogen (Estradiol), Progesterone, Cortisol, DHEA-S: Send for approval with specific clinical indications.
  • Food & Allergy Panels (Always Self-Pay):
    • IgG food intolerance panel.
    • Broad food sensitivity panels.
    • Non-specific allergy panels.

• Step-by-Step Procedure Billing:

  1. Highlight the patient and double-check the name.
  2. Navigate to Patient bills and click Bill Recalculate.
  3. Check Cashier all orders.
  4. Click DRG to verify diagnosis.
  5. Verify Eligibility.
  6. Click Doctor orders and Invoice total.
  7. Select the Payor (e.g., Sukoon) and click Authorization limits.
  8. Create a New entry and select the Billing group (e.g., Consultation mcme or Laboratory).
  9. Enter the patient amount (e.g., the co-payment amount of $50$).
  10. Click Update three times, then Update up.

• Payment Collection Process:

  1. Click Collect allocate → OK → OK.
  2. Enter the amount to be paid.
  3. Select Payment method: Credit card POS (click POS pay). If POS fails, use Credit card/Debit card option.
  4. Ask the patient to tap the card and wait for the "two bells" sound.
  5. Print both the Merchant and Patient copies.

Specialized Departmental Billing Protocols

• Psychology and Psychiatry Billing (F-Codes):

  • Payment must be collected upon arrival.
  • Check for previous visits to copy previous copayment amounts ($Old Patient$ use Deposit right side up; $New Patient$ collect copayment only at this stage).
  • Inform and coordinate with Lowwen and the nurse for medical reports required for approval.
  • If rejected, change status in the Insurance Workbench (WB) to "Rejected patient will pay."
  • To send for approval: Invoice total → Create Payor Approval Request → Insurance WB → Select CPT → Generate → Select All → Validate → Select All → Request.

• Video / Telephone Consultation Billing:

  • Price Example: Total $225$. If $10\%$ copay exists, the amount is $45$.
  • Check eligibility and send EPG ($Electronic Payment Gateway$) for copays.
  • Add a comment: "Do not proceed until paid."
  • After payment, change the status to "Arrive to bill," update the comment to "Proceed," and check for consent.

• Dental Billing Operations:

  • Dental billing always requires insurance approval ($Check with nurse for completed procedures$).
  • Requires two instances of the Bayanaty software open simultaneously.
  • Linking Pre-approvals: Copy URN to the second Bayanaty instance → Insurance WB → Subgroup: Dental Procedure → Find the Authorization Quote number.
  • Match the "Partially approve" ordered item (e.g., Composite restoration) with the "Ordered today" Initial entry by linking the tooth number (e.g., Tooth $17$).
  • Calculations: Example cleaning/consultation: $595 \times .20 = 119.068$ plus consultation $94.44 = 213.508$. Round up to $215$.

• Physiotherapy Billing and Appointments:

  • Always verify approval reports. For first sessions, ensure the referred doctor is listed.
  • In Insurance WB, look back $3$ months to check eligibility and sessions.
  • Copy session counts found after the authorization code.
  • If a bill exists as Self-Pay but should be Insurance: Go to Boris account (Password: Ihatecoffee@12) via Edge → Episode inquiry → Invoice total → Multiple override ($Billing Status: To bill$).

Patient Registration and Administrative Management

• New Patient Registration (Mandatory Fields):

  • ID Reading: Use Emirates ID reader (Sim card down) or Passport scanner (save to folder).
  • Names: First, Second (use "0" if none), and Family names.
  • Gender: M or F.
  • Dates: Use DD/MM/YYYY format.
  • Codes: Marital Status (M, S, D), Patient Category (N, U), Country (U for UAE), Education (U for unknown).
  • Contact Info: Mobile and email must be written clearly by the patient.
  • Marketing/Privacy: SMS ($Y$), Satisfaction Survey ($Y$), Language ($E$), Marketing Promo ($No$), Data Privacy ($Y$).
  • Occupation: Type "Private Private."
  • Consent: Navigate to Admin billing → Registration General Consent → Digital Signature (Patient then Staff) → Status: Authorized.

• Appointment Management:

  • Quick Multi Booking: Can be done with or without a URN. Requires Hospital (Creek), Specialty, Resource (Doctor), and Service.
  • Confirmation Calls: Perform three calls (rings). If confirmed, click red phone icon and date. If not, add notes/send WhatsApp.
  • Overbooking: If a patient is booked incorrectly, use "Overbook" on the right side, find the correct patient, and set the reason to "Walk in."
  • Block Appointments: Specify Date from/to and Time from/to. Reason codes: Clinic Procedure, Admin work, or Sick leave.

• Hassana (Vaccination) Registration:

  • For newborns, use the Mother\'s information (snip mother\'s details from Bayanaty, use text extractor).
  • If adult, register as Resident/Labor and provide occupation details.
  • Requires full name translation into Arabic via Google Translate.

Financial Operations and Reporting

• Cashier Shift Procedures:

  • Opening: Find → Create shift → Check every $2$ hours.
  • Closing: Cashier shift → Select number → Print POS detail report. Ensure the physical tally matches. Click Close Shift and print POS reconciliation/Cashier print.

• SAP / EPG Reconciliation (Supervisor Tasks):

  • SAP User: LOWWEN.A (Password: Ihatecoffee@12).
  • 131 Supervisor Review: Organization code 3CRH. Save selection.
  • 132 Supervisor Post Collection: Compare Magnati EPG statements with SAP mapping data using Excel.
  • Commission Calculation: Expected Post Confirmed Amount $-$ Total credited in mobile app. Include VAT and Commission in the reconciliation.
  • Identification: Assignments use first four 9s followed by a 10-digit Date stamp (Year/Month/Date) for Merchant ADIB.

• Refunds and Cancellations:

  • Refunds: For cash amounts greater than $2,000\,AED$, back-office approval is mandatory. Select "Back office refund," bank details, IBAN, and reason (e.g., service not done).
  • Void Payment: Cancel the bill first via "Error transaction" or "Wrong copay," use the password, and select "POS Void."

• Daily Forecast and Reports:

  • Path: Wrench tool → MCME reports → Operational report → List of appointment.
  • Download Excel → Insert Pivot Table.
  • OPD Total Calculation: Include Arrived/Departed appointments. Exclude vaccination, telephone, radiology, and physiotherapy. Calculate vaccinations by subtracting the specific packages from ambulatory totals.

Clinical Workflows and Rules

• National Immunization Schedule (Mandatory Vaccines):

  • Childhood Core: Hepatitis B, BCG (Tuberculosis), DTaP (Diphtheria, Tetanus, Pertussis), Polio (IPV/OPV), Hib, MMR.
  • Additional Routine: PCV ($Pneumococcal$), Rotavirus.
  • Travel/Special: Meningococcal (mandatory for Hajj/Umrah), Typhoid.
  • Billing Rule: Daman and Adnic are strictly "Pay and Claim" for vaccines. Set status to "Rejected patient will pay."

• Radiology Workflow:

  • Arrive patient in Radiology WB → Bill recalculate → Collect copayment before performing the service.

• Referral Types:

  • Internal: Change status of the referral to "Done" before making the new booking.
  • External: Requires two Bayanaty instances to copy Episode Claim IDs, DHA license numbers, and DRG codes from the originating clinic to MCRH billing.

• Follow-up Eligibility:

  • 7 Days: Specialist follow-up is free.
  • 30 Days: Repeated procedures/visit is free.

• Departmental Contact Extensions:

  • Main PA Reception: 5808, 5809, 5810
  • Nurse Station (Right): 5805, 5806, 5807
  • Nurse Station (Front): 5801, 5802
  • Vaccine/Pedia: 5803, 5804
  • X-ray Room: 5816
  • Dr. Simon: 5818
  • Lowwen: 5832
  • Boris: 5822
  • Leo: 5075
  • Ultrasound (Divine): 5825

Essential Tips and Insurance Caveats

• Dermatology: Pregnancy-related tests (e.g., BHCG) are always self-pay and will be rejected by insurance.
• Newborn Coverage: Babies are covered for only $29$ days under the mother\'s insurance.
• OB Gynecology: Always obtain both standard Eligibility and Maternity Eligibility. Diagnosis codes usually start with "O."
• Clinics Services Not Available at MCRH: US morphology, US breast, US vein, US DDH, HBT.
• Insurance specifics:
  • Mednet: Only Mednet Silver Premium is accepted.
  • Nextcare DEWA: Not accepted at MCRH (No direct billing).
  • NAS / Cigna / Sukoon / AXA: Always use the card number when entering details.
  • Emirates Category A: No direct billing; strictly Pay and Claim.
  • Zinc: No tariff exists with Mednet.
• System Shortcuts:
  • T tab = Current Date.
  • Y tab = Current Year.
  • N tab = Current Time.