Dubai Issues Comprehensive Overhaul Of Health Insurance Claims Management Framework

The Dubai Health Insurance Corporation (DHIC), under the Dubai Health Authority (DHA), has issued a sweeping new Health Insurance Claims Management Policy Directive, effective 16 November 2025. This directive, accompanied by a regulatory circular, revokes and supersedes all previous claims management regulations, requiring immediate compliance from all health insurance companies, third-party administrators (TPAs), and healthcare providers operating in Dubai.

Key Objectives and Scope

The new policy aims to standardize and streamline the end-to-end process of health insurance claims management, covering pre-authorization, claims submission, adjudication, settlement, reconciliation, and compliance. The regulation is designed to enhance transparency, accuracy, and efficiency, while preventing fraud and ensuring beneficiary protection. Notably, the Dubai Government Insurance Program is exempt from these requirements.

Pre-Authorization and Claims Submission: Tightened Timelines and Data Integrity

Healthcare providers must now submit pre-authorization requests within one hour of a physician's order, with insurance companies and TPAs required to respond within strict timeframes (6 hours for elective outpatient, 24 hours for elective inpatient, and immediate for emergencies). All claims must be submitted electronically via the eClaimLink system, with robust requirements for data accuracy, patient identity verification, and documentation. Non-compliance with submission timelines may result in delay fees of 0.03% of the net claimed amount per day.

Prohibited Practices and Compliance Obligations

Amongst other matters, the directive introduces explicit prohibitions for TPAs and Insurers, when entering into contracts with healthcare providers:

• Volume-based discounts
• Referral commissions,
• Performance-linked incentives that may influence treatment decisions. This includes rebates for diagnostics or denial-linked bonuses.
• Payment-for-referral schemes,
• Any financial agreements that may influence or distort clinical decision-making, or conflict with policyholder protections mandated by the DHA.
• Charging or collecting any form of annual system registration fee, administrative service charge, or platform access fee from healthcare providers, whether directly or indirectly.

All claims must be adjudicated within a 141-day cycle, with clear requirements for remittance advice, denial codes, and payment timelines (45 days for initial claims, 30 days for resubmissions). Providers are entitled to delay fees for late payments. Disputed claims may be resubmitted twice, with structured reconciliation processes and annual reconciliation sessions mandated. Manual or non-electronic submissions are strictly prohibited.

Sector-Specific Requirements

The directive details compliance standards for pharmacies, laboratories, medical test centers, and radiology centers, emphasizing electronic claims submission, accurate coding, and prohibitions on fraudulent or inflated billing practices. The directive goes on to provide the fines for violations (ranging from AED 10,000 to AED 50,000 per incident), suspension or revocation of operating permits, and other enforcement actions.

What next

The Directive is effective from 16 November 2025, and it states that all regulated entities must ensure compliance prior to this date, failing which they could be subject to enforcement. As a result of this, insurers, TPAs, providers, labs, pharmacies, radiology centers and medical test centers need to review and update internal claims management policies and procedures to ensure full compliance with the new directive. Our team is happy to assist should you require any support with understanding the requirements (and how it aligns with previous guidance from DHA/CBUAE) and any assistance you need on the implementation.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.