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Emirates Hospital Juemirah 1155

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Pre-Approval required for OP equal to or exceeding AED 1,000 / QAR 1,000 / BD 100 / OMR 100
[excluding consultation]; AND for the services detailed.
For Further Details Please Click here

Member Details

Member Name : MATHEW ANTHONY

Sponsor Name :

Policy No : 13/XI/72410/0

Membership No : 1/P/0

DHA ID : I010-000-120688531-01

Emirates Id : 784-1988-2174555-5 Date Of Birth : 26/03/1988

Area Of Cover : Local Uae Plus Elected Is VIP Member : No

IP Network : AXA 3 Start Date : 24/05/2023

OP Network : AXA 4 Expiry Date : 23/05/2024

Product : Smart Health - Gold

Deductible : 10% COINS ON ALL OP

Additional Info : NA

Benefits : R&B:PVT.ROOM, OUTP, MAT,DENT,HoT (Hide Details)

PER SERVICE : Copay applicable per service type (Eg : Laboratory, Consultation , Radiology,etc.)
CLINIC : Clinics/ Medical center INCL : Including OPT : Optical
COINS/CO-INS : Co-insurance IP : In Patient OTH : Other
CONS/CONSULT : Consultation LAB : Laboratory PH : Pharmacy
Abbreviations :
DENT : Dental MAT : Maternity PHYSIO : Physiotherapy

DIAG : Diagnostic MAX : Maximum R&B : Room and Board

EXCL/EX : Excluding OP : Out Patient RAD/RADIO : Radiology
HOSP/HOSPIT : Hospital

**** SIGNATURE PRE-APPROVAL GUIDELINES ****

In-patient Pre-approval: Within 4 hours of receiving all required documentation

All in-patient, day care and invasive procedures require pre-approval; also including but not limited to: medical
admissions, surgeries, chemotherapy and radiotherapy, dialysis, etc
Out-patient Pre-approval: Within 1 hour of receiving all required documentation
All out-patient consultations and investigations do not require approval EXCEPT in the following situations:

The net discounted amount including any investigation changes; and after removing co-pay and consultation is equal or exceeds
AED 1,000 / QAR 1,000 / BD 100 / OMR 100

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4/24/24, 12:39 PM Member Card Details
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT) & PET Scans
Day care procedures; including but not limited to Endoscopies
Speech therapy/Occupational therapy
Vitamin D test
Mammograms
Intraarticular injections
EEG/EMG/NCS
Echocardiogram/TMT/Holter Monitoring
Influenza A & B
Physiotherapy
Chiropractic treamtent
Psychiatric treatment (including consultation and pharmacy)
Maternity consultation: only the initial consultation will need pre-approval, succeeding consultations do not need pre-approval
Maternity Investigations and related treatment.
Inside Abu Dhabi: Maternity OP ( including consultation) do not require approval
Alternative Therapy not limited to Osteopath, Homeopath, Acupuncture, Ayurveda, Chinese Traditional Medicine (including
consultation and pharmacy)
Services related to health screening
Services for injuries or illness related to work, road traffic accident (RTA), or professional/dangerous sports
Pharmacy: Providers with e-Rx/PBM should use PBM for all transactions
Vaccination: Providers with e-Rx/PBM should use PBM
Dental services (including consultation and pharmacy)
Optical services
Any treatment/procedure/investigations/ medications of chronic conditions for XP / XI policies (initial doctor consultation doesn’t
require approval).

For non-Dubai based providers, please send all pre-approval requests to mb.emergency@gig-gulf.com

Benefit Name Coverage Benefit Name Coverage Benefit Name Coverage

Physiotherapy Work Related Injuries Pregnancy and Childbirth
Alternative External prosthesis or appliances Psychiatric
Dental Benefit Health Screen Benefit Vaccination
Optical Benefit

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