Capital Market Authority Regulation on Managing Health Insurance Revenue Cycles

Decision
No. KH/107/2022
On the Issuance of the Regulation of the Practice of the Activity of Management of The Revenue Cycle of the Health Insurance Claims ;Based on the Insurance Companies Law issued by Oman Sultani Decree No. 12/1979 Oman Sultani Decree No. 90/2004 on the transfer of the insurance competencies from the ;Ministry of Commerce and Industry to the Capital Market Authority Implementing Regulation of the Insurance Companies Law issued by Oman Ministerial Decision ;No. 5/1980 Oman Capital Market Authority Decision No. KH/31/2007 on the regulation of the requirements ;of licensing the practice of insurance activities ;The unified insurance policy model issued by Oman Decision No. 34/2019 ;The Health Insurance Rules issued by Oman Decision No. 78/2019 Regulation of the practice of the activity of management of health insurance claims issued by ;Oman Capital Market Authority Decision No. KH/34/2020 Approval of the Ministry of Finance; Approval of the Board of Directors of the Capital Market ;Authority ,and Based on the requirements of the public interest :The following has been decided
Article 1
The annexed Regulation on the practice of the activity of management of the revenue cycle of .the health insurance claims shall come into force
Article 2
This Decision shall be published in the Official Gazette and shall come into force from the day following the date of its publication .Issued on: 7 Dhi Al-Hijjah 1443 H Corresponding to: 6 July 2022 Abdullah Bin Salim Bin Abdullah Al-Salmi Executive Chairman of the Capital Market Authority

Regulation of the Practice of the Activity of Management of the Revenue Cycle of the Insurance Claims
Chapter 1
Definitions and General Provisions
Article 1
In the implementation of the provisions of this Regulation, the following terms and expressions :shall have the meanings assigned thereto unless the context requires otherwise .Authority: The Capital Market Authority -1 Executive Chairman: The Executive Chairman of the Authority -2 Activity of Management of the Revenue Cycle of the Health Insurance Claims: Activity of -3 regulating the document cycle and providing the service of submittal of insurance claims to the insurance company, and their follow-up and consideration, on behalf of the health service .provider Licence: Written approval issued by the Authority to practice the activity of management of -4 .the revenue cycle of the health insurance claims .Licensee: The juristic entity for which the licence is issued -5 Insurance Company: The company that is licensed by the Authority to practice the Health -6 .Insurance Activity Health Insurance Claims Management Company: The company that is licensed by the -7 .Authority to practice the activity of management of health insurance claims Health Service Provider: The health facility that is accredited by the Ministry of Health and -8 .registered at the Authority to provide health services in the Sultanate of Oman Medical Coding: The system that is approved by the Authority to manage the health -9 information and used to diagnose and describe the patients’ cases through unified medical .codes, abbreviations and terms
Article 2
The Activity of Management of the Revenue Cycle of the Health Insurance Claims shall not be .practiced unless upon obtaining a License for this purpose from the Authority The Insurance Company or the Health Service Provider or the Health Insurance Claims Management Company shall not deal with any person with no licence to practice the Activity of .Management of the Revenue Cycle of the Health Insurance Claims
Article 3
The Licensee may provide services to more than one Health Service Provider, and may conclude .agreements therewith
Article 4
The Authority may temporarily suspend the issuance of new licences for an adequate duration, .whenever this measure is deemed necessary
Article 5

The Licensee shall not own or operate or manage any Health Service Provider or any companies operating in the Insurance Sector or Health Insurance Claims Management, unless according to .the requirements and controls issued by the Authority in this regard
Chapter 2
Licensing
Article 6
:The following conditions shall be met in order to obtain a Licence The person applying for a licence shall take the corporate form according to the provisions of -1 .the legislation in force The capital of the company shall not be less than (OMR 300.000) without prejudice to the -2 .minimum capital of the company according to the Law of Commercial Companies The sole objective of the company is to practice the Activity of Management of the Revenue -3 .Cycle of the Health Insurance Claims The company shall have a full-time director meeting the conditions determined by the -4 :Authority, particularly the following a- To hold a university degree or its equivalent from any recognised university or educational institution in the Sultanate of Oman, in the specialisation of Health-Care .Management, Insurance, Business or Revenue Cycle Management b- To have an experience in the field of his specialisation of not less than (7) years after .obtaining the required degree .c- To submit a non-conviction certificate The company shall have a full-time physician meeting the conditions determined by the -5 :Authority, particularly the following a- To hold a Licence from the entity deemed competent to practice the profession of .medicine b- To have a practical experience of not less than 3 years after obtaining a degree in the .field of Management of the Revenue Cycle of the Health Insurance .c- To submit a non-conviction certificate Appoint at least 3 medical coders provided that they hold the Medical Coding Licence -6 .determined by the Authority and the certificate approved in this regard
Article 7
The preliminary approval application shall be submitted for the practice of the Activity of Revenue Cycle of the Insurance Claims on the form prepared for this purpose, and the submittal of such application does not impose any obligation on the Authority. The application shall :include the following data and documents .Basic data of the licence holder -1 True copy of the articles of incorporation, statute, commercial register and certificate of -2 .affiliation to the Chamber of Commerce and Industry of Oman Statement including the names and nationalities of the contributors at the company, or the -3

shareholders concerning the shareholding companies, owning capital shares of not more than .5% .Invoice confirming the payment of the prescribed fees -4 .Any other documents or data determined by the Authority -5
Article 8
The applicant for a Licence, in case of getting the preliminary approval, shall submit to the Authority within (60) days at most from the date of getting such approval, the following documents, in order to obtain the Licence, otherwise such approval shall be deemed as if it :never existed and this does not result in any impacts towards the Authority .Copy of the title deed or the rental contract of the suggested headquarters -1 Occupational Risks Insurance issued by any insurance companies licensed in the Sultanate of -2 .(Oman, provided that its value is not less than (OMR 100.000 .Bank certificate stating that the requested capital is paid -3 Unconditional bank guarantee in the interest of the Authority, provided by any licensed bank -4 in the Sultanate of Oman, as per the value and duration determined by the Authority, to ensure that the licensing requirements are properly met, and the requirements stipulated in this .Regulation are fulfilled .Statement proving that a full-time director and physician are appointed at the company -5 .Statement proving the appointment of 3 medical coders -6 Statement confirming adherence to the procedures that ensure full compliance with the -7 .requirements of the fight against money-laundry and terrorism financing Detailed report about the electronic system used by the applicant, and the procedures that -8 .ensure its protection and its effectiveness Plan of recruitment, training, qualification of the individuals working for the applicant for a -9 .licence .Any other documents determined by the Authority -10
Article 9
The Licence shall be issued for 2 years by a decision of the Executive Chairman within a duration that does not exceed 60 days from the date the applicant for a Licence fulfils the requirements .and conditions stipulated in this Regulation The Licence may be renewed for one or more similar durations based on an application submitted to the Authority using the form that is prepared for this purpose, within (60) days .maximum from the expiration of the Licence A decision on the renewal application shall be issued within (45) days from the date of its .submittal, otherwise the application shall be deemed rejected For the purpose of renewal, it is necessary to verify whether all conditions and requirements .related to the Licence are met
Article 10
The Authority shall inform the applicant for a Licence or the Licensee – as the case may be – in

case the licence application or the renewal application does not meet the conditions and requirements stipulated in this Regulation - of the inadequacies of the application. A delay that does not exceed (30) days from the date of notification in this regard shall be given to adjust .such inadequacies, otherwise the application shall be deemed as if it never existed
Article 11
The Authority may request the applicant for a Licence to provide any additional clarifications, data or information, whenever this is deemed necessary, to decide on the licence application, within a duration that does not exceed (30) days from the date the applicant meets the .conditions and requirements stipulated in this Regulation
Article 12
:The Authority may cancel the Licence in any of the following cases In case the Licensee does not initiate the Activity of Management of the Revenue Cycle of the -1 Health Insurance Claims within (6) months at most from the date of receiving the Licence, .without any permission or excuse that may be accepted by the Authority In case the Licensee waives the Licence or the rights and obligations arising therefrom to third -2 .parties without the approval of the Authority In case the Licensee violates the decisions or instructions related to the Activity of -3 Management of the Revenue Cycle of the Health Insurance Claims or the provisions stipulated in .this Regulation
Article 13
The Authority may take any of the following procedures towards the offending Licensee instead :of cancelling the Licence Warning the Licensee to eliminate the grounds of the offence within (7) days at most from the -1 .date of the warning Suspending the Licence for a duration that does not exceed (30) days that may be renewed for -2 .a similar duration
Article 14
:The Licence shall be terminated in any of the following cases Termination of its validity duration without renewal within the delay stipulated in Article (9) -1 .of this Regulation, or in case the Authority rejects its renewal Issuance of a final judgement on the bankruptcy of the Licensee, or on the dissolution and -2 .liquidation thereof, or in case of the expiration of its term Proving that the Licensee has obtained the Licence through fraud, falsification or forgery, or by -3 .submitting false data or information The Licensee requests the termination of the Licence, provided that, in this case, the Authority -4 approves such request; it is necessary to verify whether the Licensee has fulfilled all the .obligations thereof
Chapter 3
Obligations of the Licensee
Article 15

The Licensee shall abide by the rules of practice of the profession, as well as the ethics issued by .the Authority, and shall achieve the level of quality in the services provided thereby
Article 16
The Licensee shall link the electronic system used for the work thereof to the electronic health insurance system at the Authority, and to any other electronic system determined by the .Authority, according to the controls and conditions determined in this regard
Article 17
The Licensee shall use the Medical Coding Licence approved by the Authority in the electronic .system thereof
Article 18
The Licensee shall provide necessary protection to the electronic system used for the work thereof, and shall protect the data and information from any hacking or access of any authorised person, and shall set the mechanisms that ensure the recovery of data or information in case of .their loss for any reason It is necessary to take any procedure and measure deemed necessary to face any emergency or in case any technical malfunction or failure occurs in the electronic system, in order to avoid the suspension of the work process and to ensure the continuity of the operation thereof efficiently .and effectively
Article 19
The Licensee shall include all the papers and documents related to the Activity thereof in the licence number issued thereto, and shall inform the Authority of any change that occurs in the .data or information included in the Licence within (7) days from the date of such change
Article 20
The Licensee shall conduct all the operations related to the activities thereof in the Sultanate of Oman, and shall maintain confidentiality of all data, information, documents and papers accessed thereby while practising such activities. The Licensee shall not disclose to third parties any of the aforementioned unless based on the explicit permission of the Authority or the explicit consent of the person to whom the confidential data, information and documents are related, or for the implementation of the law or any judicial order issued by the Public .Prosecution or the Competent Court – as the case may be
Article 21
:The Licensee shall abide by the following towards the Health Service Provider .Manage the electronic system of the Health Service Provider -1 Verify the identity of the insured person and the extent of his eligibility to get the treatment -2 .service Verify whether the data entered to the electronic system of the Health Service Provider -3 concerning the illness of the insured person and the diagnosis and treatment of such illness is in .conformity to the codes of the approved Medical Coding System Handling the claims rejected by the Insurance Company and the Health Insurance Claims -4 .Management Company, and finding and correcting the problem related to such rejection Training and qualification of the persons working for the Health Service Provider, for the -5 purpose of using the approved Medical Coding Systems as well as the systems that may be

.adopted in the future
Transfer the Health Insurance Claims arising from the electronic treatment services of the -6 insured person to the Insurance Company or the Health Insurance Claims Management Company, on behalf of the Health Service Provider, and ensure that they received such claims .within the time-limits determined for this purpose Follow up the collection of funds for the treatment services provided to the insured person, in -7 addition to the amounts reimbursed for the rejected claims, and verify that they are paid by the Insurance Company within the timelimits determined for this purpose, and make the necessary .financial settlement Determine the fees of the treatment services provided to the insured person in agreement -8 .with the Insurance Company or the Health Insurance Claims Management Company Document all the treatment services provided to the insured person in the Electronic System -9 .of the Health Service Provider Collect the amount of contribution of the insured person in the cost of the medical -10 expenditures determined in the Unified Insurance Policy Model and its annexes, upon his visit to .the Health Service Provider, and transfer such amount to the Insurance Company
Article 22
:The following is prohibited to the Licensee
Impose fees, or obtain a benefit or receive any amounts from the Health Service Provider or -1 the Insurance Company or the insured person other than the financial consideration agreed .upon with the Health Service Provider Conclude a contract with a Health Service Provider that is not registered in the Registers of the -2 .Authority Conduct operations or procedures related to the Activity of Management of the Revenue Cycle -3 .of the Health Insurance Claims outside the Sultanate of Oman Perform any act that directly or indirectly affects the selection of the Insurance Company or -4 .the Health Service Provider by the insured person .Operate with a Medical Coding Licence that is not approved by the Authority -6
Chapter 4
Supervision and Control
Article 23
The Authority shall prepare a register for the registration of the issued Licences, provided that such registration includes the licence number, date of issuance, and validity duration, as well as sufficient information and data about the Licensee and the headquarters of exercise of the Activity of Management of the Revenue Cycle of the Health Insurance Claims, and other data and .information related to the Licences
Article 24
The Licensee shall provide to the Authority any data, information and other papers related to .the implementation of the provisions of this Regulation whenever requested
Article 25

The Licensee shall provide the Authority with a copy of the contracts concluded with the Health Service Provider within (30) days from the date of their conclusion, shall inform the Authority of any amendments made to such contracts and shall also provide it with a copy in this regard .within (15) days from the date of such amendment
Article 26
The Licensee shall inform the Authority of the fundamental information that affects the financial status thereof or the procedures adopted at the company or any decision taken concerning the appointment of the Chairman and members of the Board of Directors, within (30) days from the .date of notification of the information or issuance of the decision
Article 27
The Licensee shall submit a report every (4) months to the Authority about the acts of fraud or .misuse of the health benefits occurring during the period included in the report
Article 28
:The Licensee shall assume the following
Appoint an external auditor among the auditors who are licensed to operate in the Sultanate -1 of Oman, and approved at the Authority. Such auditor shall keep the auditing books and registers according to safe and guaranteed methods, and submit them to the Authority .whenever the latter so requests Submit the annual budget and audited final accounts to the Authority within (90) days from -2 .the end of the fiscal year
Article 29
The Licensee shall submit to the Authority a report approved by the external auditor within (90) days from the end of the fiscal year, and such report shall include the number and names of the Health Service Providers dealing therewith during the concerned fiscal year and the due .commission from every Health Service Provider
Chapter 5
Fees
Article 30
:The CMA shall charge the following fees
(Amount (RO Type of service S
(One Thousand Five Hundred) 1,500 Consideration of licensingapplication 1 (Two Thousand Five Hundred) 2,500 Issuance or renewal of the Licence 2 (Twenty) 20 Dataamendment 3 4 Request to access to the papers and registers (Twenty) 20 (Twenty) 20 Request of copies or extracts 5
Chapter 6
Administrative Sanctions
Article 31

An administrative fine of (OMR 3000) three thousand Omani Riyals shall be imposed on .whomever violates the provisions of Articles (16, 17, 18 and 19) of this Regulation
Article 32
An administrative fine of (OMR 5000) five thousand Omani Riyals shall be imposed on whomever .violates the provisions of Articles (24, 25, 26, 27, 28 and 29) of this Regulation
Article 33
An administrative fine of (OMR 7000) seven thousand Omani Riyals shall be imposed on .whomever violates the provisions of Articles (5, 6, 20 and 22) of this Regulation