Nextcare Claim Process

What is Nextcare?

Nextcare is a Third Party Administrator (TPA) that specialises in providing comprehensive health insurance management and administration services. 
As a TPA, Nextcare acts as an intermediary between insurers and healthcare providers. It plays an important role in the efficient processing and settlement of health insurance claims.

Key Functions and Services of Nextcare

1. Health Insurance Management: Nextcare offers complete health insurance management services for insurers and other healthcare payers. This includes handling the entire claims process — from submission to settlement.
2. Network Providers: Nextcare has contracts with various healthcare facilities such as hospitals, clinics, laboratories, and pharmacies. These network providers offer direct settlement of bills, i.e. you, as an insured individual, can access services without paying upfront. You can simply present your insurance card or national ID, depending on the country where the services are obtained.
3. Claims Processing: By managing claims on behalf of insurers, Nextcare ensures that medical claims are processed efficiently and accurately. This reduces the administrative burden on insurance companies and provides policyholders with timely reimbursements and approvals.
4. Customer Support: Nextcare provides extensive customer support through call centres, mobile apps, and online portals. You can easily track your Nextcare claims, submit necessary documents, and get assistance with any insurance-related queries.
5. Healthcare Access: By facilitating direct settlement and maintaining a wide network of healthcare providers, Nextcare enhances access to quality healthcare services for insured individuals.

How to Apply for a Nextcare Reimbursement Claim?

To apply for a Nextcare reimbursement claim in the UAE, you need to follow a few detailed steps. 

This process can be completed through Lumi, which is an online platform provided by Nextcare for managing insurance claims.

1. Access Lumi Website or App

• Lumi is Nextcare's digital portal for managing claims and other insurance-related activities. You can use it to submit, track, and manage your reimbursement claims online.
• You can access Lumi through Nextcare's official website or by downloading the Lumi app from your respective app store.

2. Register or Log In

If you are a new user, you need to register by creating an account using your personal details and insurance policy information.

3. Go to Claims

Once logged in, go to the ‘Claims’ section on the dashboard.

4. Submit a New Claim

Click on ‘Submit New Claim’. Make sure you have the following details ready —

• Healthcare provider name, service date, and description of the service
• Physician name and contact details
• All necessary supporting documents, such as medical reports, itemised bills, and original receipts

5. Complete Claim Information

Fill in all the required fields with accurate information about your medical services and expenses.

6. Upload Supporting Documents

• Medical report signed by your doctor and stamped by the clinic/hospital
• Itemised medical form with details of the current illness, past medical history, clinical history, and prescribed medical tests or medicines
• Medical results if any (e.g., test results, radiology reports)
• Itemised medical invoices from the clinic/hospital

7. Submit the Claim

• After uploading all the necessary documents, click on ‘Submit Claim’ to finalise the process.

8. Confirmation and Notification

• Once your claim is submitted, you will receive a notification by email confirming the submission. Nextcare will review the claim and notify you of the status.

Documents for the Nextcare Reimbursement Claim Process

To submit a reimbursement claim with Nextcare, you need to provide specific documents — 

1. Medical report
2. Itemised medical invoice
3. Itemised medical form signed by your doctor and stamped by the clinic/hospital
4. Medical results (if any, such as test results and radiology reports)
5. Original receipts

Make sure all documents are complete and accurate to ensure a smooth reimbursement process. 

What are the Components of the Nextcare Reimbursement Form?

The Nextcare reimbursement claim form requires specific information to be filled out accurately. Here are the components of the Nextcare claim form — 

Administrative Details

Healthcare Provider Name, Patient’s Name, Date of Service, Patient’s Telephone Number, Date of Birth, Sex, Emirates ID Number, Email Address, Insurance Company, Account Name, UAE IBAN , UAE Bank Name, UAE Swift Code

Subjective Information (To be Completed by the Physician)

1. Symptoms as Described by the Patient (Chief Complaint)
2. Date of Present Symptom Onset
3. Date Patient First Felt Same/Similar Symptoms
4. Current Treatments/Medications (if any, including type and duration)

Objective/Assessment (To be Completed by the Physician)

1. Vital Signs (Temperature, Pulse, Respiration, Blood Pressure)
2. Past Medical and Surgical History
3. Clinical Details and Description of Present Case
4. Cause of Condition (e.g., Physical Illness, Accident, Maternity, Preventive, Psychiatric, Dental, Work Related)
5. Nature of Condition (e.g., Acute, Chronic, Confirmed, Suspected)
6. Assessment or Diagnosis (with Diagnosis Codes)
7. Relation to Other Assessments or Diagnoses (if applicable)

Medical Plan

1. Itemised Original Invoices and Applicable Prescriptions/Reports/Results
2. Costs (Consultation, Physiotherapy, Pharmacy, Laboratory/Radiology/Other)
3. Total Charges
4. In-Patient Requirement and Length of Stay (if applicable)
5. Discharge Summary (with Itemised Invoices, Reports, and Receipts)
6. Treating Physician’s Name and Contact Information

Authorisation and Signature

1. Authorisation for the Release of Medical Information
2. Signature and Stamp of Treating Physician
3. Patient’s Signature (or Parent if Minor)
4. Date

How Can You Follow Up on Your Reimbursement Health Insurance Claim?

To follow up on your reimbursement health insurance claim with Nextcare, you have two main options: using the Lumi app or calling the Call Center number on the back of your insurance card. 

Here is a detailed guide to help you track your claim status — 

Using the Lumi App

1. Open the Lumi App
   • Download and install the Lumi app from your app store if you haven't already.
   • Log in using your username and password.
2. Navigate to Claims
   • Go to the ‘Claims’ section.
   • Select ‘View Claims’ to see a list of all your submitted claims.
3. Check Claim Status
   • You can search for any submitted reimbursement claim to know its current status.

Comprehending Claim Statuses

1. Registered: The claim has been submitted but not yet reviewed by the Nextcare team
2. Authorised: The claim has been reviewed and approved by the Nextcare team
3. Pending for Beneficiary Response: The claim is received, but some mandatory documents are missing — you need to submit these documents for further processing
4. Processed: The claim has been reviewed and is either totally or partially approved, ready for settlement
5. Settled: The claim has been settled, and the money has been transferred to your account or your beneficiary's account
6. Declined: The claim has been denied because it does not meet the eligibility criteria as per your insurance policy
7. Not Used: The claim was authorised but later cancelled

Calling the Call Center

1. Local Call Center Number
   • You can dial the Call Center number found on the back of your insurance card for assistance.
   • Provide your claim details to the representative who will help you track the status.

How to Apply for a Nexcare Direct Claim?

To apply for a Nextcare direct claim (cashless claim) in the UAE, simply follow these steps — 

1. Book an Appointment: Before visiting a medical facility, call and book an appointment with your chosen physician or specialist. While booking, confirm that your insurance policy is accepted by the healthcare provider.
2. Visit the Healthcare Provider: Attend your scheduled appointment and consult the physician or specialist.
3. Provider Submits Request: The healthcare provider will submit a request for the required medical services directly to Nextcare, especially if pre-approval is needed.
4. Nextcare Approval: Nextcare will review the request and directly provide approval to the healthcare provider within the pre-agreed turnaround time.
5. Payment Details: The healthcare provider will inform you about any costs that you need to cover directly, such as co-payments, co-insurance, deductibles, or any non-covered services, as per your policy terms and conditions. They will also inform you about any further treatments required, including the date and time for those treatments.

Key Points to Remember

1. Pre-Approval: Make sure that the services you need require pre-approval from Nextcare. This is generally necessary for more extensive procedures or treatments.
2. Copay and Deductibles: Understand your policy's terms regarding co-pays and deductibles, as these are amounts you may need to pay out-of-pocket.
3. Policy Coverage: Confirm that the healthcare provider accepts your insurance policy to avoid any unexpected charges.

How to Contact Nextcare in Emergency Situations?

Under emergencies, contacting Nextcare quickly and efficiently is important. 

Given below are the steps and contact details you need to keep in mind — 

Emergency Coverage

Policy Terms and Conditions: Emergency situations are covered as per your policy terms and conditions. Always check your insurance policy to understand the specifics of your coverage.

Contact Details

Local Call Center: The best way to get immediate assistance is by calling the local call centre number on the back of your insurance card. This number is specifically for emergencies and can guide you through the necessary procedures.

Additional Contact Options

1. WhatsApp Support
   • For Bahrain, Egypt, Kuwait, Oman, and UAE: +971 56 344 8951
   • For Lebanon: +961 81 504 015
   • For Qatar: +974 55 066 687
2. Mobile App Support: If you need help with the Nextcare mobile app, you can email appsupport@nextcarehealth.com for assistance.
3. Member Care: For general inquiries and member-related concerns, contact membercare@nextcarehealth.com.

Steps to Take in an Emergency

1. Identify the Situation: Make sure that the situation qualifies as an emergency as per your policy.
2. Call the Call Center: Use the local call centre number on your insurance card to get immediate help.
3. Follow Instructions: The call centre will provide specific instructions and clarify procedures for handling your emergency.
4. WhatsApp and Email Support: If you are unable to call, use the WhatsApp numbers or email addresses provided above for support.

What Can be the Reasons for Nextcare Health Insurance Claim Rejection?

1. Non-Covered Benefits
   • The most common reason for claim rejection is that the claimed benefit is not covered under your policy terms and conditions. Always review your policy to understand what is and isn’t covered.
2. Standard Exclusions and Exceptions
   • Every insurance policy has standard exclusions and exceptions. Common exclusions include:
     • Conditions not disclosed at the time of policy purchase
     • Tests to identify allergies may not be covered
     • Supplements and alternative treatments like homoeopathy or acupuncture might be excluded
     • Certain dental procedures and braces are often not covered
     • Costs related to contraceptives may not be reimbursed
     • Injuries from activities deemed hazardous by the insurer
     • Preventive health services and vaccines not mandated by insurance authorities
3. Incomplete Documentation
   • Missing or incomplete documentation can lead to claim rejection. Make sure that all the necessary documents, such as Nextcare reimbursement forms, reports, and receipts are submitted correctly.
4. Submission Errors
   • Incorrect or incomplete information on the Nextcare claim form can result in rejection. Double-check all entries before submission.
5. Late Submission
   • Claims submitted beyond the allowed time frame may be rejected. Check your policy for the specific submission deadline, which is usually between 30 to 60 days after treatment.
6. Unapproved Treatments
   • Treatments that require prior approval from Nextcare and were not approved before being administered can lead to claim denial.

Tips to Avoid Claim Rejection

1. Review Your Policy: Understand your policy’s terms, conditions, and exclusions by referring to the benefits highlights or Table of Benefits provided by your insurer.
2. Complete Documentation: All necessary documents like the Nextcare reimbursement form, relevant reports, bills, and others must be included and correctly filled out (if applicable) when submitting your claim.
3. Pre-Approval for Treatments: For treatments that need prior approval, make sure to obtain it before proceeding with the medical services.

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