SAICO Claim Form

Self Assessment
SAICO Claim Form

Approval Number:

To be completed by Reception/Nurse:

HealthcareProvider:

Member No:

Insurance Co.:

SAUDI ARABIAN INSURANCE CO. LTD

EmployeeNO:

Email:

customerservice@saicohealth.com

Patient Name:

Patient File No:

Category:

Normal

Date of Birth:

Marital Status:

Nationality:

Sex:

Patient Email:

Policy:

Mobile:

Plan Type:

Visit Date:

Inception Date:

Expiry Date:

New Visit

Follow Up /Refill

Walk In

Referral

To be completed by Attending Physician:

Inpatient

OutPatient

Day Care

Emergency

Chief Complaint and Main Symptoms:

Diagnosis:

Description/Services

Suggestive line(s) of management: Kindly, enumerate the recommended investigations, and/or procedures for Outpatient approvals only:

Is Case Management Form (CMF 1.0) included? Yes No

Please specify possible line of management when applicable:
Estimated length of stay: Days Expected Admission: Expected Discharge :

I hereby certify that ALL information mentioned is correct and that the medical services shown on this form were medically indicated and necessary for the management of this case.
Treating Physician:

Date:

I hereby certify that all statements and information provided concerning patient identification and the present illness or injury are TRUE.
Name & Relationship(if guardian) :

Date :

*Provider's approval/Coding Staff must review/code the recommended service(s), allocate cost, and complete the following:

Completed/Coded by:

Date :

For Insurance Company Use Only:

Approval Number:

Approval Validity:

Status

Approved

Partial Approved

Rejected

Additional Info Required

Cancelled

Decision Note:

Decision By:

*Cases Totally or Partially Approved is subject to final Clinical and Claim Review.*

*Cases with status Waiting Additional Information will be auto-rejected after 10 consecutive auto reminders in such cases SAICOHealth will not be liable for any amount.*

Insurance Officer:

Decision Date: