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QLM Protocol & Medical Guidelines Antenatal Care Guideline QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa © 2024-updated Version | ANC Protocol Updated.pdf |
GESTATION/ WEEK INVESTIGATION DESCRIPTION FREQUENCY COMMENTS Booking Visits 6-8 weeks Laboratory BHCG CBC Urine Dipstick Blood Group (ABO) FBS or RBS Syphilis serology (RPR) Hepatitis B & C Serology Rubella Ig G Toxoplasma Ig G & Ig M HIV1 Covered 11-14 Weeks U/S Laboratory Ultrasound Nuchal Translucency Urine Dipstick... | ANC Protocol Updated.pdf |
This guideline for routine antenatal care / low risk pregnancy Reference : https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx#A | ANC Protocol Updated.pdf |
QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Jan 2024Obesity -Bariatric Procedures | Bariatric Surgery Guidelines.pdf |
❑ QLM cover the bariatric surgery and endoscopic procedures as an option for patients resistant to other non-surgical interventions and met the following criteria: Endoscopic Bariatric Procedures I. BMI ≥27 kg/m2 with obesity-related complications. II. BMI ≥30 kg/m2 without obesity-related complications III. BMI ≥40 kg... | Bariatric Surgery Guidelines.pdf |
The following must be considered in members aged ≤18 Years: Underlying causes of obesity and co-morbidities should be treated first. Additional measurements to support the diagnosis of obesity. Report from Paediatric specialists or Paediatric Gastroenterologist and Dietitian are required along with surgeon report. ❑ Fo... | Bariatric Surgery Guidelines.pdf |
References: https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx https://www. uptodate. com/contents/bariatric-surgery-for-management-of-obesity-indications-and-preoperative-preparation?source=hi story_widget#H2963932 https://www. ncbi. nlm. nih. gov/books/NBK588750/ | Bariatric Surgery Guidelines.pdf |
QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Dental Guidelines | Dental Guidelines 1.pdf |
Dental Guidelines Select the correct category (Dental Category) and tooth number (for applicable services) to prevent unnecessary denials. Services evaluation andapproval based onthe Core privileges (for General Dentist) &Non-core privileges (forcertified specialists) only asper QCHP guidelines. Services validation and... | Dental Guidelines 1.pdf |
Dental Guidelines Myofunctional Appliances coverable only Ifthepolicy mentions orthodontic treatment covered irrespective Iiof age or interceptive orthodontic treatment covered. Transparent & ceramic brackets and Invisalign or clear Aligners are not covered unless mentioned in the TOB of the policy. Cosmetic and Congen... | Dental Guidelines 1.pdf |
Dental Guidelines Bone grafts andflap surgeries must accompany a detailed dental report,pre-service x-ray, periodontal chart, andoperative notes. Surgical and complicated extraction must accompany adetailed operative note and pre-service x ray. Orthodontics claims require Cephalogram, OPG, photos, Orthodontic assessmen... | Dental Guidelines 1.pdf |
Service Description Pre-Service Post-Service Accepted Radiology Method Root Canal Treatment Yes Yes IOPA Complicated Extraction/Surgical extraction/Impacted /Embedded molars /Cysts of jaw Yes No IOPA or OPG Multiple restorations above 3 At a time, Interproximal caries, large carious lesions. No Yes OPG or IOPA Implants... | Dental Guidelines 1.pdf |
QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa Dental Protocol (Pre-Approval &Claims) | Dental Protocol 2.pdf |
Select the correct category (Dental Category) in Pre-Approval sub mission to prevent un-necessary denials. Crown cementation is the part and parcel of main procedure. Re-cementation is coverable only for old dislodged crowns. Partial Denture is one service code for 1 to 5 teeth in no,as per agreed tariff. Services eval... | Dental Protocol 2.pdf |
Pre-procedure diagnostic x-ray showing the indication and post-procedure x-ray is mandatory in the following procedures: i. Root Canals ii. Crowns iii. Bridges iv. Dentures Pre-procedure diagnostic x-rays showing the indication is mandatory in the following procedures: i. Orthodontic (Cephalogram, OPG, visit record wit... | Dental Protocol 2.pdf |
Service Description Pre-Service Post-Service Accepted Radiology Method Root Canal Treatment Yes Yes IOPA Complicated Extraction/Surgical extraction/Impacted /Embedded molars Yes No IOPA or OPG Multiple restorations above 3 At a time,Interproximal caries, large carious lesions. No Yes OPG or Bitewings Implants Yes Yes O... | Dental Radiology 2.pdf |
Hypertension and Diabetes-Follow up QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa | getCustDocStreamForExtApp.pdf |
➢Initial investigations to diagnose Hypertension-HTN (confirmed High Blood Pressure measurement) are ; urine general, Serum cr eatinine, Lipid Profile, Fasting plasma glucose or Hb A1C (Hb A1C test if plasma glucose above the normal range or diabetic member). ➢Medical history and BP measurements to be clearly mentioned... | getCustDocStreamForExtApp.pdf |
References : Ministry of Public Health of Qatar-Clinical Guidelines https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx#D Up To Date https://www. uptodate. com/contents/search Pub Med Visit Pub Med website athttps://www. ncbi. nlm. nih. gov Web MD Visit Web MD website at https://ww... | getCustDocStreamForExtApp.pdf |
Pentacam coverage Protocol QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa | Pentacam Coverage Protocol.pdf |
Pentacam coverable in following conditions: Corneal dystrophies covered unless genetic or congenital in origin. Refer to policy table of benefits for coverage. Complications of transplanted cornea, (if corneal transplant covered by the policy). Post-traumatic corneal scarring. pre-operative evaluation for intraocular l... | Pentacam Coverage Protocol.pdf |
Refences; Up To Date https://www. uptodate. com/contents/overview-of-contact-lenses?search=corneal%20topography&source=search_result&selected Title=2~15 0&usage_type=default&display_rank=2 https://www. uptodate. com/contents/search?search=corneal%20topography&sp=0&search Type=PLAIN_TEXT&source=USER_INPUT&search Contr o... | Pentacam Coverage Protocol.pdf |
Dupixent ➢Approved in severe cases of Atopic Dermatitis only if there is proven failure with other topical and systemic therapies or contraindications. ➢Specify level of severity aligned with POEM / SCORAD score result. ➢Atopic dermatitis lines of treatment: 1stline: topical corticosteroids 2ndline: Tacrolimus and Pime... | PHARMACY - Dupixent Circular.pdf |
Dynastat 40mg Contains the active ingredient Parecoxib (COX-2 inhibitor). Indicated in the short-term management of pain. Adult dosage: maximum 80 mg per day. 3 days is the maximum period of treatment, if needed. | PHARMACY - Dynastat 40mg.pdf |
Fatty Liver Disease Diet and exercise to promote weight loss is the initial therapy. Pharmacological therapy is reserved for the following conditions only: 1. Weight loss failure. 2. Biopsy-proven NASH with fibrosis stage ≥ 2. 3. Biopsy-proven NASH with fibrosis stage ≥ 2 and diabetes. Diagnosis Treatment NASH but with... | PHARMACY - Fatty Liver Disease.pdf |
Iron Treatment with an iron preparation is justified only in the presence of a demonstrable iron-deficiency state. Oral formulations are indicated in iron deficiency w/o anaemia. ➢If there is poor absorption, consider Iron-Vitamin C combinations. ➢Reducing the dose frequency is a strategy to reduce GI side effects. Par... | PHARMACY - Iron Supplements.pdf |
Migraine Severity, number of attacks, and onset date are required. NSAIDs and Triptans (e. g. Naramig ) are considered first-line therapy. CGRP antagonists ( e. g. Aimovig )are considered second line prophylactic agents. CGRP antagonists approval criteria : Acute (moderate to severe) cases: M ore than four headache... | PHARMACY - Migraine.pdf |
Ondansetron ➢Dopamine antagonists commonly used for nausea and vomiting are Metoclopramide and Domperidone. ➢Serotonin Antagonists (e. g. Ondansetron) approval criteria: 1. Considered as 1stline for nausea and vomiting associated with the following cases only: Chemotherapy Post-surgery 2. Considered as 2ndline for the ... | PHARMACY - Ondansetron.pdf |
Proton Pump Inhibitors (PPIs) Provide the onset date and frequency of GERD symptoms (intermittent/frequent). Specify the stage of GERD (mild, moderate, severe). Concomitant use of PPIs with NSAIDS or other is considered prophylactic unless proved to have a medical necessity. Follow step-up approach in mild cases an... | PHARMACY - PPI.pdf |
Repatha ➢Indicated in Homozygous Familial Hypercholesterolaemia and Mixed hyperlipidaemia (↑cholesterol and ↑ LDL) cases. ➢Continuous treatment for a minimum of 3 months prior to any modification in the sequence of (Statins, Ezetimibe, Repatha)respectively. ➢Approval criteria : 1. Full medical and family history. 2. Li... | PHARMACY - Repatha.pdf |
Resolor Indicated for the treatment of chronic constipation only. Chronic constipation diagnosis is based upon the presence of symptoms for at least 3 months (with symptom onset at least 6 months prior to diagnosis). Considered as the final line of treatment if laxatives fail to provide relief. Dosing: Once daily for 4... | PHARMACY - Resolor.pdf |
Topical Anti-Edematous Pain Relievers To enable smooth processing of topical anti-edematous pain relievers that contain the active ingredients (Aescin and Methyl Salicylate) such as Reparix Gel, Reparil Gel,etc... , please ensure to share the following: 1. Full diagnosis with detailed history as per below: Acute blunt... | PHARMACY - Topical Anti-Edematous Pain Relievers.pdf |
Topical Anti-Edematous Pain Relievers Please take into consideration the following important points: Maximum approved duration of treatment is 7 days. Number of packets to be approved is shown in the example below: E. g. Apply to back twice daily for 7 days. 1 tube (50 grams) will be approved for the requested daily d... | PHARMACY - Topical Anti-Edematous Pain Relievers.pdf |
Diabetes Mellitus (Type 2) G. P. prescriptions are accepted for newly-diagnosed patients in emergency cases and for 14 days only. Specialist referral is required in complicated cases. Metformin is considered first-line solely or in combination for all newly-diagnosed cases, if not, please provide the reason. Hb A1c... | PHARMACY -Diabetes Mellitus Type 2.pdf |
Dry Eyes To enable smooth processing of dry eye cases, please ensure to share the following: 1. Ophthalmologist treating prescription. 2. Full specific diagnosis (e. g. If the patient is diagnosed with Conjunctivitis, please specify the type: Bacterial, Viral,,,,,, etc). 3. Full symptoms and complaints that are relate... | PHARMACY -Dry Eyes.pdf |
PHARMACY GUIDELINES ISSUED BY QLM LIFE & MEDICAL INSURANCE COMPANY QPSC LICENSED AND REGULATED BY QATAR CENTRAL BANK PREPARED BY : DR. CHRISTINA KHOURY christina. khoury@qlm. com. qa DATE: FEB. 2024 www. qlm. com. qa | PHARMACY GUIDELINES - FEB 2024.pdf |
ITEM INDICATION REMARKS Eye Lubricants Covered for 1 month only for acute conditions and 3 months for chronic conditions. 1 type of drops or gel Please dispense enough quantity according to the logic 1ml =20 drops not exceeding 2 MD bottles/month. Please dispense enough quantity for UD ampoules according to requested d... | PHARMACY GUIDELINES - FEB 2024.pdf |
Permixon, Prostenal BPH if prescribed with other medications for treatment only and not prophylaxis Check for herbal treatment coverage PPIs GERD / Duodenal ulcer / Peptic Ulcer H. PYLORI 2 months only if newly-diagnosed 2-3 weeks according to prescribed duration Prophylaxis with other NSAIDs / anti-biotics /... not co... | PHARMACY GUIDELINES - FEB 2024.pdf |
Pharmacy Guidelines 2024 (Page 4)Propolsaft Syrup Cough Check for herbal treatment coverage Take care that immuno boosters are a company exclusion. Omacor Hyperlipidemia (TGs 500 mg/ dl ( 5. 65 mmol/ l or higher)Covered for the shared policies only (Go to pg. 6) Mouthwashes Bepanthene Cream Pharyngitis and Tonsilitis E... | PHARMACY GUIDELINES - FEB 2024.pdf |
Pharmacy Guidelines 2024 (Page 5)ITEM INDICATION REMARKS Cystone, Alka-Ur Kidney Stones and other indications as per the leaflet Treatment only not prophylaxis | PHARMACY GUIDELINES - FEB 2024.pdf |
Pharmacy Guidelines 2024 (Page 6)POLICY HOLDER Amiri Yacht Tadmur Holding Vodafone Qatar MOFA BEIN Media Group YES YES YES YES YESYES YES YES YES YESOMACOR COVERAGE GLUCOSAMINE COVERAGE YES YESQatar Central Bank Qataris/Non-Qataris Gulf Warehousing Company Premier A | Premier B | Advantage C QNB Qatar Energy LNG Qatar ... | PHARMACY GUIDELINES - FEB 2024.pdf |
QLMPre-Authorization Requirements for The Common In-Patient (IP) & Outpatient (OP) Procedures | Pre-Authorization Requirements.pdf |
QLMIn-Patient (IP) Procedures A. Nasal surgery ( Septoplasty, FESS, SMD). B. Cholecystectomy. C. Joints ligament or tendon tear repair surgery ( ACL, meniscus repair... ). D. Tonsillectomy, Adenoidectomy and Myringotomy. E. Renal stone Procedures. F. Hernia repair. | Pre-Authorization Requirements.pdf |
QLMNasal surgery (Septoplasty, FESS, SMD) ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the detail s of conservative treatment and past surgical-history. N. B: Frequency of Sinusitis attacks in last year is required to facilitate evaluation of FESS cases. ➢Et... | Pre-Authorization Requirements.pdf |
QLMCholecystectomy ➢Medical report including all manifestations (symptoms and signs) details and duration along with the frequency of biliary col ic attacks in the previous month. ➢Ultrasound Report. ➢Verify the presence of history of bariatric surgery. In cases where applicable, then detailed history required such as ... | Pre-Authorization Requirements.pdf |
QLMJoints, ligaments or tendons tears repair surgery ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment,if applicable and past surgical-history. ➢Confirm if there is history of trauma, In the event of trauma, please provide a... | Pre-Authorization Requirements.pdf |
QLMTonsillectomy, Adenoidectomy and Myringotomy ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment and past surgical history. ➢Frequency of tonsilitis attacks per year, frequency of otitis media attacks & degree of tonsillar ... | Pre-Authorization Requirements.pdf |
QLMRenal stone removal ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment and past-history of surgeries. ➢Radiology report. ➢Verify the presence of a history of bariatric surgery, along with the date of the surgery and post-o... | Pre-Authorization Requirements.pdf |
QLMHernia Repair ➢Medical report including all manifestations (symptoms and signs) with its details, duration and past surgical history. ➢Radiology report/s,( In case of inguinal hernia repair please specify the type of Hernia whether it is direct or indirect). | Pre-Authorization Requirements.pdf |
QLMAdmission and admission extension ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with plan of treatment a nd past-history of surgeries. ➢Submission of Supporting Reports such as labs investigations and radiology reports,etc. Documents required for extension eval... | Pre-Authorization Requirements.pdf |
QLMOutpatient procedures (OP) A. Oesophago-Gastro-Duodenoscopy (OGD) B. Colonoscopy C. Epidural injection D. Intra-articula r Injection E. Skin lesion Removal | Pre-Authorization Requirements.pdf |
QLMOesophago-Gastro-Duodenoscopy ➢Medical report including all manifestations (symptoms and signs),illness duration,the provided conservative treatment and p ast surgical history. ➢Verify if the member on Proton Pump Inhibitor-(PPI) Medication, In cases where applicable, kindly provide the medication name, duration and... | Pre-Authorization Requirements.pdf |
QLMColonoscopy ➢Medical report including all manifestations (symptoms and signs) with its details and duration along with the details of cons ervative treatment and past-surgical history. ➢Supporting reports such as Laboratory Reports (e. g CBC, Stool /Analysis or occult blood stool),previous histopathology report ,etc... | Pre-Authorization Requirements.pdf |
QLMEpidural injection ➢Medical report including all manifestations (symptoms and signs),duration, details of conservative treatment and past-history of surgeries. ➢Details of initial conservative treatment ( oral medications, physiotherapy sessions & etc.. ) with progress report from phy siotherapist. ➢Radiology report... | Pre-Authorization Requirements.pdf |
QLMIntra-Articular injection ➢Medical report including details of symptoms and signs along with details of conservative treatment. ➢Radiology report. ➢Name of medication will be injected. ➢Details of the initial conservative treatment done for same illness. | Pre-Authorization Requirements.pdf |
QLMSkin lesions Procedures ➢Medical report including diagnosis, etiology,duration and necessity of requested procedure. ➢Radiology report for applicable cases. | Pre-Authorization Requirements.pdf |
OP QLMOutpatient laboratory services ➢Claim form including symptoms and signs,illness duration along with the past-medical history. ➢Preliminary investigations results are required for evaluation for the secondary/ additional requested investigations. | Pre-Authorization Requirements.pdf |
QLM Protocol & Medical Guidelines © 2022-2023 1 QLM Life & Medical Insurance Company Q. P. S. C We bring to you innovative and tailor-made insurance solutions coupled with a world-class level of service. www. qlm. com. qa | QLM Protocol Medical Guidelines 1.pdf |
TABLE OF CONENTS 1. General Prior-Authorization & Claims Guidance.................................................................................................. 3 2. Coverage of VITAMIN D Test................................................................................................................................ | QLM Protocol Medical Guidelines 1.pdf |
General Prior-Authorization & Claims Guidance Allrequested investigations and services aresubject toresult ofthepre-liminary investigations results and policies TOB coverage. Wrong selection ofservice category inpre-approval submission willresult inservice denial inclaims. Physiotherapy and Vaccination services must... | QLM Protocol Medical Guidelines 1.pdf |
4Routine blood screening forvitamin Ddeficiency isnotrecommended inindividuals who arenotatriskand inthe absence ofspecific clinical concerns. Coverable inhighly suspected patients with indicated symptoms such asmetabolic bone diseases. Test canberepeated after sixmonths ofcontinuous regular treatment fordeficiency ... | QLM Protocol Medical Guidelines 1.pdf |
Initial investigations todiagnose Hypertension-HTN (confirmed High Blood Pressure measurement) are;urine general,Serum creatinine,Lipid Profile,Fasting plasma glucose or Hb A 1C(Hb A 1Ctest ifplasma glucose above the normal range ordiabetic member). Medical history and BPmeasurements tobeclearly mentioned intheclaim ... | QLM Protocol Medical Guidelines 1.pdf |
Thyroid stimulating hormone testing based on history and examination for the initial assessment ( not routinely recommended). Transaminase levels (alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and creatine kinase before starting lipid-modifying treatment then annually if member on statin. Vit B... | QLM Protocol Medical Guidelines 1.pdf |
Forsymptomatic members TSH only iscoverable and canbefollowed by T4&T3ifitresults isbelow thenormal range or T4only ifitisabove thereference range. Fortreatment adjustment only TSH iscoverable three month after treatment then Biannually /orannually for euthyroid status. Antithyroid Antibodies (such as Anti-Thyroid P... | QLM Protocol Medical Guidelines 1.pdf |
Ifthehistory and physical examination failed todiagnose thecase then further investigations willbeapproved based ondoctor evaluation ofthe Pain acuity, duration, intensity,......etc. aswell aspatient age and gender in thebelow sequences ; Laboratory tests Plain radiographs (ifbowel obstruction, bowel perforation, or... | QLM Protocol Medical Guidelines 1.pdf |
Testing for Helicobacter pylori (H. pylori ) coverable; If the clinician plans to offer treatment for positive results or After Completion of treatment for documented H. pylori infection in order to confirm eradication. Serology not coverable for above mentioned conditions Endoscopic testing coverable if there is ... | QLM Protocol Medical Guidelines 1.pdf |
Endoscopy not coverable forscreening purposes/ orsurveillance orifrelated touncovered disease asper policy table ofbenefits (TOB). Colonoscopy not covered for Screening/surveillance,such asscreening for Colon polyp orcancer, or Inflammatory bowel disease unless thebenefit covered bypolicy. Not recommended torequest ... | QLM Protocol Medical Guidelines 1.pdf |
References : Ministry of Public Health of Qatar-Clinical Guidelines https://www. moph. gov. qa/english/Our Services/eservices/Pages/Clinical-Guidelines. aspx Up To Date https://www. uptodate. com/contents/search Pub Med Visit Pub Med website athttps://www. ncbi. nlm. nih. gov Web MD Visit Web MD website at https://www.... | QLM Protocol Medical Guidelines 1.pdf |
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