Claims Rules

What are Claims Rules?

Claims Rules aim to guide the medical community on what constitutes an appropriate MediShield Life claim. They are not clinical practice guidelines per se but are derived from them.

Claims Rules make clear what is an appropriate procedure claim under MediShield Life in 5 key areas:

• Clinical indication

• Setting of procedure

• Frequency of claims allowed

• Surgical coding

• Modality of treatment for specific procedures

Claims Rules cover surgical procedures under a range of medical specialties. Claims Rules focus on procedures that have high utilisation, and/or a certain degree of ambiguity or potential for abuse.

• Claims Rules are developed by MOH-appointed workgroups comprising public and private sector specialists, in consultation with representative specialist groups

• Claims Rules are based on published literature, prevailing clinical practice, cost-effective guidelines, and

• Claims Rules are verified against available past claims data to ensure that they cover the vast majority of claims that are medically appropriate

How are Claims Rules implemented?

MOH intends to roll out Claims Rules progressively every year and phased by specialties. Claims Rules will be refreshed every 2 to 3 years to ensure they keep in tandem with medical advances.

• The Claims Rules for Gastrointestinal Endoscopy and Related Procedures [PDF, 594 KB] were released in August 2022

• Cardiology [PDF, 586 KB] and Ear, Nose and Throat (ENT) [PDF, 370 KB] Claims Rules were released in September 2023

• Urology, Ophthalmology, General Surgery and Hepatobiliary, and Orthopaedics (Hip, Knee) Claims Rules are currently in the pipeline

• Before each set of Claims Rules are enforced, a transition period (which is generally about six months) will be provided. During the transition period, doctors, and medical institutions whose cases are adjudicated, will be informed of the outcome for learning purposes

Non-compliance to Claims Rules

• Doctors with cases that are not in compliance with Claims Rules will be asked for their clinical rationale, should such cases be selected for medical adjudication by an independent Panel of experts appointed by the MediShield Life Council

• If a claim is adjudicated to be non-compliant with the Claims Rules, doctors and medical institutions will be asked to rectify the claim and the MediSave and MediShield Life monies improperly paid out under the claim should not be recovered from the patient

• Doctors with non-compliances to Claims Rules that cannot be medically justified will be monitored closely and enforced against. Refer to section on enforcement under claims adjudication

View "5 Facts on Claims Rules" infographic [PDF, 1.1 MB]