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Medical Reimbursement
Other Claims
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Medical Reimbursement

To be filed by Applicant
Insured's company name *
Patient's name
Mobile
Email *
Medical Insurance Card number
Is the treatment incurred in the
Treatment visit date
Medical Provider Name
Treating physician name
Medical record/file number
City of the treatment place
Country name *
Reason of cash claim submission
Cash claim amount
Application date
Employee's signature
To be filed by MalathCare
Is the treatment incurred in the
Treatment visit date
Diagnosis name
Diagnosis code
Name of the claim processor
Date and signature
Claims Audited by Dr.
Approved cash amount
Stamp
How to make a cash claims reimbursement

When submitting a cash claims reimbursement, please follow these steps and procedure:

1. Claims with the following completed documents and requirements will quicken its process:
  • Filed Reimbursement application form.
  •  Copy of MalathCare card and ID card. 
  • Original doctor prescription: dated, signed & stamped
  •  Original detailed invoice signed and stamped by the provider.
  • Original Results for diagnostic tests and/or Medical reports for In-clinic Procedures.
  •  Inpatient Claim: Itemized hospital invoice, medical report and Discharge Summary should exist as a supportive document- for the claim incurred.

2. A cash claim should not be a combination of several visits to Doctors, medicine requested or tests done on different dates.

3. Preferred KSA prices will be applied in case of out of network claims.

4. A deduction of 20% will be applied for out of network claims except in emergency cases.

5. All claims that will be incurred outside KSA should have a prior approval letter from Malath Care except for emergency cases - please attach the approval copy.




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