1/6/23, 3:02 AM BUPA | PreAuth Details

Preauth Request # : 76481408 Reply Letter Ready 

Follow-Up Request Cancellation Request Renewal Request

Provider Insured
Dr Mohammed Al Fagih
Name: Name: Abdulaziz Faisal Alshammari
Hospital
‫اسم مزود الخدمة‬: ‫اسم المؤمن عليه‬:
ID. Card:
/ ‫رقم الهوية الوطنية‬ 1194124382
‫االقامة‬
Insurance Co: Bupa Arabia Age: Sex:
3 M
‫شركة التأمين‬: ‫بوبا العربية‬ ‫العمر‬: ‫الجنس‬:
Policy
Saudi National Bank
Holder:
SNB
‫صاحب الوثيقة‬:
Patient File
Dept: Policy No.:
No.: 15861922 33530205
‫القسم‬: ‫رقم العقد‬:
‫رقم ملف المريض‬:
Class:
Staff
‫درجة التغطية‬:
Provider Fax Expiry
No.: Date of Visit: Date:
06/01/2023 31/12/2023
‫رقم فاكس مزود‬ ‫تاريخ الزيارة‬: ‫تاريخ انتهاء‬
‫الخدمة‬: ‫التغطية‬:

Reference to your pre-authorisation request (page 1) for ‫) لعميلنا صاحب‬1 ‫إشارة إلى طلب الموافقة الخاص بكم (صفحة‬
our member (details listed above). We, Bupa Arabia
‫ وبناءًا على المعلومات الطبية المحدودة‬،‫التفاصيل المذكورة أعاله‬
replying on the membership and limited medical
information supplied provided in your request took the ‫ قررنا نحن بوبا العربية إتخاذ القرار المذكور‬،‫والمقدمة من قبلكم‬
decision mentioned below: ‫أدناه‬

Approval No.: 76481408

Pre-authorisation Status: ‫رقم الموافقة‬:
‫حالة طلب الموافقة‬:

Comments: Approval 05/02/2023

‫مالحظات‬: Validity:
‫مدة صالحية الموافقة‬:
Room Type:
Single Room
‫نوع الغرفة‬:

Service Required:
Privacy - Terms

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1/6/23, 3:02 AM BUPA | PreAuth Details

Service Supply Supply Supply Service Description Qty Notes

Code Period From To ‫وصف الخدمة‬ ‫مالحظات كمية‬
‫مدة الخدمة رمز الخدمة‬ ‫من تاريخ‬ ‫الى تاريخ‬
, Service is referred
Thermometer Device 1 to, Lemon Medical
Pharmacy

Additional Comments
‫مالحظات اضافية‬

Insurance
Date & Time
Officer API User 06/01/2023 02:59:59
‫لوقت والتاريخ‬:
‫مسؤول التامين‬

Above decision based on the information received:

Member Detail
Member Card Issue
Abdulaziz Faisal Alshammari 0 Mobile No:
Name No:
Membership Member Patient File
33530205
No: Id/Iqama No:
Verification
Contract No: 50147100
ID:

Provider Detail
Provider Physician
24053 DR Fax No:
Code Name:

Treatment Detail
Abdulaziz / Present History PediaHistory of Present
Illness : 3 years old male presented to ER because of
fever and sorethroat for the last three days,then he
developed skin rash since yesterday,generalized but
mainly neck& upper chest,itchy. ;on and off fever;no
Chief
shortness of breathing;he vomited once,not
Complaints Diagnosis Diagnosis
projectile,,and diarrhoea,once,watery,not containing J03
and main Code: Desc:
blood or mucous. ;good oral intake. ;Duration :
symptoms
3DAY(S);General Examination and Review -
PediatricsGeneral : ;Mode of Arrival : Ambulatory
;Oedema : No ;Lymph Nodes
;O/E:conscious,febrile,not pale,hydrated,not
distressed fever,sorethroat,skin rash

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1/6/23, 3:02 AM BUPA | PreAuth Details

Treatment Date of
O 06/01/2023 Quantity:
Type Admission:
Department Length of Estimated
PED 0
Type Stay: Amount:
Last
Expected
Menstrual
Delivery in
Period in
Hijri
Hijri
Last
Expected
Menstrual
Delivery in
Period in
Gregorian
Gregorian

Maternity Detail
Exemptions Y Referral: Y Chronic:
Work
RTA Infertility: N
Related:
Gravida Para: Live:
kindly refeer the PT to ((((AL-NHDI Pharmacy))))
Possible line KINDLY ATT VSC from att files ((((Temperature (°C) Other
of treatment 38.4 )) ((Respiratory Rate Preshool 28 )) ((Heart Rate Conditions:
Preschool (Beats/Min) 132 ))
Check-up Congenital: Psychiatric:
Blood
Vaccination Pulse:
Pressure:
Maternity
Abortion: Death:
Type
Duration of
Temperature:
Illness:

ServiceCode SupplyPeriod SupplyFrom SupplyTo Referral ServiceDescription Qty

Y BRAUN Ear thermometer 1

Diagnosis Code Diagnosis Description

J03 Acute tonsillitis

Member
Service Description SAR Deductible Approved Amount
Contribution

Thermometer Device 369 0 0

*Estimated amounts will be updated based on provider price list as final value during claims.

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1/6/23, 3:02 AM BUPA | PreAuth Details

‫يرجى المالحظة أن هذه الموافقة تخضع لشروط وأحكام االتفاقية‬

Kindly note: This approval is subject to the terms and
conditions of the signed agreement including agreed ، ‫الموقعة بين الطرفين بما في ذلك أسعار االتفاقية الشاملة المتفق عليها‬
package prices and price list and the customer policy
limits and exclusions. Further, BUPA Arabia confirms
،‫كذلك‬.‫وقوائم األسعار بما في ذالك حدود تغطية العمالء واالستثناءات‬
cover for the member's treatment as specified in the ‫تؤكد بوبا العربية تغطيتها لعالج العضو بما تم ادراجه في خانة‬
coverage details field based on the limited
information supplied to us during pre-authorisation. ‫الحاالت المدرجة ضمن التغطية إستنادًا الى المعلومات المحدودة والتي‬
BUPA Arabia reserves the right to fully or partially
‫تحتفظ بوبا‬.‫تم إفادتنا بها خالل طلب الموافقة على الخدمات الطبية‬
deny the payment for any of the above treatment
during the claim processing stage in case one of the ‫العربية بحق الرفض الكلي او الجزئي بخصوص سداد تكاليف الخدمات‬
following reasons (which does not constitute a
numerous clauses of events) becomes apparent:
‫الطبية عند المطالبة بها اذا ما توفر أحد االسباب التالية ( التي ال تشكل‬
1. If the diagnosis, treatment or any other material : ) ‫بنود عديدة من األحداث‬
fact alters from those disclosed during pre-
authorisation ‫اذا كان التشخيص او العالج او اي حقائق اخرى مخالفة لما‬
2. If the line of treatment is not according to
.‫ورد في طلب الموافقة‬
internationally recognised medical standards and in
line with the M.O.H approved practices ‫عدم تطابق أو توافق العالج او الخدمة الطبية الممنوحة مع‬
3. In case of forgery
‫المعايير المتعارف عليها دوليا او مخالفته لما نصت عليه لوائح‬
.‫و قوانين وزراة الصحة السعودية‬
.‫في حالة االحتيال او التزوير‬

Saudi Medical Insurance Standardization - United Claim & Approval Form (SMIS-UCAF 1.0)

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