Base Doctor's Notes and Medical Report

Chief Complaint Recorded by Dr. SABA NOORI ABDULHASSAN ABDULHASSAN, Employee License No: 14076, on 03/03/2024 at 19:06:17 37 y, P4+1 Previous 3 LSCS, LCB 2018 1 miscarriage (24 weeks) No contraception since 6 months, previously on local contraception Was using condoms Last seen in December to check follicle, which was 18mm without OI, and HCG was given, but no conception PMHX: Nil PSHX: LSCS Medical free FSH 8, LH 6, AMH 0.6 No HSG Good ovulation each month, took only one month OI but no FS done Husband: 49 years old, staying together, works in Occidental as an engineer, non-smoker, no medical or surgical history No SA LMP: 26/02/2024 CD 7 TVS: Uterus with triple line 6mm, Right ovary leading follicle 17mm, Left ovary with small follicle Plan: Was on OvaCare for 4 months SA to be done FS on Thursday HSG to be done Pap smear Chief Complaint Recorded by Dr. SABA NOORI ABDULHASSAN ABDULHASSAN, Employee License No: 14076, on 05/03/2024 at 19:43:42 For FS No DF Social-Economic Assessment Recorded by Dr. LOTFOLAH AHMAD POOR KEIVANI, Employee License No: PRV022, on 09/06/2021 at 12:02:32 Patient never smokes Patient never uses drugs Patient never drinks Patient lives with family Allergies Recorded by Dr. ELENA LUKANSKAJA, Employee License No: 13555, on 09/05/2023 at 17:11:42 No known allergies Vitals Recorded by Not Selected. RUBY RAJAN, Employee License No: 0885, on 03/03/2024 at 18:49:37 Tympanic Temperature: 36°C Heart Rate: 66 beats/min Respiration: 22/min O2SAT: Room air O2 Sat: 99% Blood Pressure: 115/52 mmHg Height: 162 cm Weight: 91.9 kg BMI: 35 Pain Assessment Recorded by Not Selected. RUBY RAJAN, Employee License No: 0885, on 03/03/2024 at 18:49:37 Pain: No Nursing Notes Recorded by Not Selected. REEM BABIKER, Employee License No: Not Listed, on 05/03/2024 at 17:11:40 Follow up Diagnosis Recorded by Dr. SABA NOORI ABDULHASSAN ABDULHASSAN, Employee License No: 14076, on 03/03/2024 at 19:06:19 N92.6 - Irregular menstruation, unspecified (Primary) Plan of Care Lab Tests Recorded by Dr. SABA NOORI ABDULHASSAN ABDULHASSAN on 03/03/2024 at 19:39:59 Cytology Gynecological [PAP smear- Thin Prep] Radiology Recorded by Dr. SABA NOORI ABDULHASSAN ABDULHASSAN on 03/03/2024 at 19:35:10 Ultrasound - OPD - WHS Immunization History Recorded by Not Selected. MARIE VENZUELA RACELIS, Employee License No: 1364, on 09/05/2023 at 17:00:28 Status: Unsure Medication Recommended/Advised Recorded by Dr. SABA NOORI ABDULHASSAN ABDULHASSAN, Employee License No: 14076, on 03/03/2024 at 19:39:20 ULTRA CO Q10 60S, Dosage: 1 TAB, Frequency: Daily, Route: Oral, Duration: 30 days OVACARE TABLETS 30's, Dosage: 1 TAB, Frequency: Daily, Route: Oral, Duration: 30 days

Claim Validation Report

Claim Details:

• Patient ID: Unique Identifier
• Name: Anonymos for privacy
• Age: 37
• Gender: Female
• Date of Visit: 03/03/2024
• Chief Complaint: Irregular menstruation
• Insurance Policy Number: Patient's insurance policy number
• Practitioner's Name and Signature: Dr. SABA NOORI ABDULHASSAN ABDULHASSAN

Validation Results:

Adherence to General Agreement:

• Adherence: Adheres
• Reason for Adherence: The claim follows the guidelines set forth in the General Agreement. The patient is covered under the policy, and the services provided are within the scope of covered services, including outpatient treatments for medical necessity.

Adherence to Insurance Policy Coverage:

• Adherence: Does Not Adhere
• Reason for Adherence: The treatment for infertility and associated tests (FS, HSG) are explicitly excluded from coverage under the policy, which states that infertility treatments and contraceptive supplies are not covered. Thus, the claim does not adhere to the insurance policy coverage.

Doctor's Note and Medical Report Analysis:

• ICD-10 Codes: The doctor's note contains the ICD-10 code N92.6 for irregular menstruation, which is appropriate for the chief complaint.
• CPT Codes: No specific CPT codes were provided in the doctor's note for the procedures or tests recommended (FS, HSG, PAP smear). This lack of coding can lead to claim rejection.
• Possible discrepancies:
  • Missing CPT codes for the recommended tests and procedures.
  • Claiming for infertility-related tests that are not covered under the insurance policy.
• Analysis: The doctor's note indicates that the patient is undergoing tests related to infertility, which is not covered by the insurance policy. Although the ICD-10 code for the chief complaint is correct, the absence of CPT codes and the nature of the services requested raises significant concerns regarding the validity of the claim.

Claim Status Recommendation:

• Claim Status: Rejected
• Reason for Status: The claim does not adhere to the insurance policy coverage as infertility treatments and associated tests are explicitly excluded. Additionally, the absence of CPT codes for the requested tests further supports the rejection of the claim.

General Recommendations:

It is recommended that the patient consult with the healthcare provider to ensure that all necessary procedures and tests are covered under the policy before proceeding. It is essential to obtain correct CPT codes for all procedures performed to avoid rejection of future claims. The patient should also explore alternative coverage options for infertility treatments, as these are not included in the current policy. Additionally, maintaining thorough documentation and clear communication with the insurance provider can help streamline the claims process and prevent discrepancies.

Amended Claim:

[Oman] Medical Insurance Claim Report