CONNECT WITH Fourtune

MEDICAL SERVICES AGREEMENT






Between

FORTUNE TPA HEALTHCARE L. L. C.

(Hereafter known as fortune care)

And

Hereafter known as Health care provider (HCP)

THE AGREEMENT


Fortune Care and HCP have entered into this Agreement in order that the latter may provide healthcare services to eligible beneficiaries.

In return for the Covered Services provided, Fortune Care agrees to pay the provider. Subject to the following terms and conditions, the eligible medical expenses arising from Out Patient treatment rendered to Fortune Care’s Members in accordance with the prices notified in this Agreement.

This Agreement will cover outpatient expenses for Economic Network.

This Agreement does not cover the payment of any charges for services provided to a Member by the HCP which have not been pre-authorized where required or which are not covered by the Policy.

This Agreement entitles Fortune Care Members under different network if medical necessary treatment if available at your clinic.

It is the responsibility of the HCP to validate the identity of the insured persons by checking the medical card issued by Fortune Care

Agreement: This agreement between Fortune Care and HCP that specifies health care services to be provided to valid Members which will be paid by Fortune Care.

Medical Condition: Any dental condition except the services under exclusion list.

Member: A Group/ Plan Member or Eligible Dependent:

Conditions to payment of charges

Clinic charges will be paid on the strict understanding that the Treatment to which they relate is.

Medically necessary having regard to the Member’s Medical Condition.

Pre-authorization

Pre-authorization is required for all the services taken at your facility.

Pre-authorization is required for any treatment involving pre-existing conditions.

Charging of Members

No other charges will be made to Members and the HCP will not recover or seek to recover additional amounts directly from a Member other than:

Deductibles/co-payment in accordance to the covered Plan.

Costs incurred by the member which are not covered by the Policy including, for the avoidance of doubt,

any excess or cost sharing associated with the Policy.



Price list:

As per the below.

Out-patient services

Plan members will have direct access to Dental Practitioners for consultations and treatments.

Radiology and Imaging Services, Laboratory Services, Other Diagnostic Services

Diagnostic tests such as pathology, X-Rays related to dental.

Pharmacy Services

Drugs prescribed at the HCP by Dentist are covered under this Agreement. The types of medicines used shall be appropriate, effective and available. Fortune Formulary drugs must be followed.

At the discretion of the treating physician, drugs may be prescribed for a period not exceeding 14 days for routine ailments and a maximum of 30 days, for cases requiring long-term treatment.



Card Sample:





Submission of Bills to Fortune Care

The HCP may submit all the bills for all the covered services provided to the Members as per the details given below

Claims must be submitted before 10th of every month . Resubmission is permitted only once within 15 days of remittance advice.

Note: Preapproval code is mandatory for all the claims submitted.



Paper claim submission:

Must reach our office before 10th of every month for the previous month with below details

1. Online generated claim form

2. Approval letter copy

3. Original invoices

4. Reports of the investigation performed.



Payment of Bills

Fortune Care will use all reasonable endeavors to process eligible claims for payment within forty five (45) days of receipt by the Fortune care.

Fortune Care will not accept liability for paying claims received after 10th of every month for the previous month.



TERMINATION


Termination on Notice

Fortune Care or HCP may terminate this Agreement on any twelve month anniversary of the effective date on giving at least 30 days prior notice in writing. Fortune Care liability shall be limited to the expenses incurred up to the effective date of the termination. In the event of this Agreement being terminated the HCP shall no longer hold themselves out as having a special relationship with Fortune Care, and will be removed from the Fortune Care HCP Directory.


NOTE: KINDLY FOLLOW THE DETAILS AS GIVEN IN THE PROVIDER MANUAL TO AVOID REJECTIONS



GENERAL


Any confidential information about each Party’s business that becomes known to the other Party,

Including but not limited to information about systems and Members and the details of this Agreement (including the charging rates), shall be held strictly confidential and shall not be disclosed to any third party except by prior written consent of the other Party or if the information becomes available to the general public. The parties agree to take such steps as may be necessary to ensure that their employees, agents, officers and directors having access to such confidential information are bound by the terms of this confidentiality provision as if they had signed this Agreement themselves.

This agreement shall be construed in accordance with the laws of the United Arab Emirates.

IN WITNESS whereof this Agreement has been signed today by duly authorized representatives of the parties

For and on behalf of Fortune TPA Healthcare LLC

Name: Dr. Mohmmed Mirshad Chelapramkandy

Title: Network Manager

Signature: … … … … … … … … … … … … … … … … …

For and on behalf of Health care provider

Excluded (non-basic) healthcare services.

1. Healthcare services, which are not medically necessary.

2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.

3. Home nursing; private nursing care; care for the sake of travelling.

4. Custodial care including:

(1) Non-medical treatment services;

2) Health-related services which do not seek to improve or which do not result in a change in the medical condition of the patient.

5. Services which do not require continuous administration by specialized medical personnel.

6. Personal comfort and convenience items (television, barber or beauty service, guest service and similar incidental services and supplies).

7. All cosmetic healthcare services and services associated with replacement of an existing breast implant. Cosmetic operations which are related to an injury, sickness or congenital anomaly when the primary purpose is to improve the physiological functioning of the involved part of the body and breast reconstruction following a mastectomy for cancer are covered.

8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control programs, services, or supplies.

9. Medical services utilized for the sake of research, medically non-approved experiments and investigations and pharmacological weight reduction regimens.

10. Healthcare services that are not performed by an Authorized Healthcare Service Providers.

11. Healthcare services and associated expenses for the treatment of alopecia, baldness, hair falling, dandruff or wigs.

12. Health services and supplies for smoking cessation programs and the treatment of nicotine addiction.

13. Any investigations, tests or procedures carried out with the intention of ruling out any foetal anomaly.

14. Treatment and services for contraception.

15. Treatment, services and surgeries for sex transformation, sterilization or intended to correct a state of sterility or infertility or sexual dysfunction. Sterilization is allowed only if medically indicated and if allowed under the law.

16. External prosthetic devices and medical equipment.

17. Treatments and services arising as a result of hazardous activities, including but not limited to, any form of aerial flight, any kind of power-vehicle race, water sports, horse riding activities, mountaineering activities, violent sports such as judo, boxing, and wrestling, bungee jumping and any professional sports activities.

18. Growth hormone therapy.

19. Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids.

20. Mental health diseases, both out-patient and in-patient treatments, unless it is an emergency condition.

21. Patient treatment supplies (including for example: elastic stockings, ace bandages, gauze, syringes, diabetic test strips, and like products; non-prescription drugs and treatments) excluding supplies required as a result of Healthcare services rendered during a medical emergency.

22. Allergy testing and desensitization (except testing for allergy towards medications and supplies used in treatment); any physical, psychiatric or psychological examinations or investigations during these examinations.

23. Services rendered by any medical provider who is a relative of the patient for example the insured person himself or first degree relatives.

24. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary during treatment.

25. Healthcare services for adjustment of spinal subluxation.

26. Healthcare services and treatments by acupuncture; acupressure, hypnotism, massage therapy, aromatherapy, ozone therapy, homeopathic treatments, and all forms of treatment by alternative medicine.

27. All healthcare services and treatments for In-Vitro Fertilization (IVF), embryo transfer, ovum and sperms transfer.

28. Elective diagnostic services and medical treatment for correction of vision.

29. Nasal septum deviation and nasal concha resection.

30. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related investigations, treatments or procedures.

31. Healthcare services, investigations and treatments related to viral hepatitis and associated complications, except for the treatment and services related to Hepatitis A.

32. Birth defects, congenital diseases and deformities.

33. Healthcare services for senile dementia and Alzheimer’s disease.

34. Air or terrestrial medical evacuation and unauthorized transportation services.

35. In-patient treatment received without prior approval from the insurance company including cases of medical emergency which were not notified within 24 hours from the date of admission.

36. Any in-patient treatment, investigations or other procedures, which can be carried out on out-patient basis without jeopardizing the insured person’s health.

37. Any investigations or health services conducted for non-medical purposes such as investigations related to employment, travel, licensing or insurance purposes.

38. All supplies which are not considered as medical treatments including but not limited to: mouthwash, toothpaste, lozenges, antiseptics, milk formulas, food supplements, skin care products, shampoos and multivitamins (unless prescribed as replacement therapy for known vitamin deficiency conditions); and all equipment not primarily intended to improve a medical condition or injury, including but not limited to: air conditioners or air purifying systems, arch supports, exercise equipment and sanitary supplies.

39. More than one consultation or follow up with a medical specialist in a single day unless referred by the treating physician.

40. Health services and associated expenses for organ and tissue transplants, irrespective of whether the insured person is a donor or a recipient. This exclusion also applies to follow-up treatments and complications.

41. Any expenses related to immunomodulators and immunotherapy.

42. Any expenses related to the treatment of sleep related disorders.

43. Services and educational programs for handicaps.

Healthcare services outside the scope of health insurance.

1. Injuries or illnesses suffered by the insured person as a result of military operations of whatever type.

2. Injuries or illnesses suffered by the insured person as a result of wars or acts of terror of whatever type.

3. Healthcare services for injuries and accidents arising from nuclear or chemical contamination.

4. Injuries resulting from natural disasters, including but not limited to: earthquakes, tornados and any other type of natural disaster.

5. Injuries resulting from criminal acts or resisting authority by the insured person.

6. Injuries resulting from a road traffic accident.

7. Healthcare services for work related illnesses and injuries as per Federal Law No. 8 of 1980

concerning the Regulation of Work Relations, its amendments, and applicable laws in this respect.

8. All cases resulting from the use of alcoholic drinks, controlled substances and drugs and hallucinating substances.

9. Any investigation or treatment not prescribed by a doctor.

10. Injuries resulting from attempted suicide or self-inflicted injuries.

11. Diagnosis and treatment services for complications of exempted illnesses.

12. All healthcare services for internationally and/or locally recognized epidemics.

13. Healthcare services for patients suffering from (and related to the diagnosis and treatment of HIV – AIDS and its complications and all types of hepatitis except virus A Hepatitis.

LIST OF PHARMACEUTICAL EXCLUSIONS

Vitamins and Minerals (unless prescribed along with antibiotics)

Vaccines

Medication given for infertility

Contraception/birth control medicines and devices

Medication for Psychiatric/Psychological problems and Mood altering Medications Soaps and Shampoos both Medicated and non medication Cosmetic Preparations (Creams and Lotions etc)

Supplementary medicines Proteins, Amino Acids and weight gain or weight loss medicines General Antiseptic Solutions

Tooth Brushes, Toothpaste, Dental Floss etc

Baby formulas, Milk, and Nutrition

Contact lens Preparations

Crutches, Braces, Slings, Lumbar Supports, Corsets, Cervical Collars, other joint supports

Breasts Pumps, Massage machines exercise machines etc

Orthopedic shoes, heel pad/Arch support, etc

Orthotics, Mouth Guards etc

Bandages

Hearing Aids, Glucostrips etc

Hormonal replacement therapy



Price List

Kindly Check on ALL the prices