While the primary health care strategy is the core of all interventions; referral care is an essential part of access to comprehensive health services UNHCR Public Health Operational Gui
The TPA
To streamline access to UNHCR support, a Third Party Administrator (TPA) is contracted to act as the intermediary between beneficiaries and healthcare facilities The TPA verifies the beneficiary's status as a UNHCR Person of Concern (PoC) and assesses the eligibility of their medical condition for support Additionally, the TPA oversees the financial and medical auditing of the care provided and handles payments to hospitals on behalf of UNHCR.
The UNHCR hospital network
The TPA collaborates with a network of public and private hospitals nationwide to provide care for refugees, with inclusion determined by UNHCR based on factors such as proximity, service availability, and cost-effectiveness This network undergoes continuous review to adapt to changing needs, and generally, UNHCR does not endorse care provided in hospitals outside this network For a complete list of participating hospitals, refer to Annex 2.
Referral care support
UNHCR facilitates access to referral care for Persons of Concern (PoCs) through a cost-sharing model, where the TPA establishes standardized fees with contracted hospitals based on Ministry of Public Health (MoPH) rates UNHCR covers 75% of costs exceeding 100 USD, while beneficiaries are responsible for the first 100 USD of their medical bills To alleviate financial burdens, if a beneficiary's expenses reach 800 USD, UNHCR pays the remaining costs Additionally, for certain special categories, UNHCR's financial support is increased, as detailed in section 14.4.
UNHCR has established a maximum reimbursement limit of \$10,000 for a single admission, with the exception of specific care types such as neonatal and burns intensive care, which can extend the ceiling to \$15,000 Additionally, the total reimbursement for one household within a year is capped at \$30,000.
Seeking care
Beneficiaries can easily access health care information through multiple channels, including leaflets, text message campaigns, social media, and community outreach Primary Health Care centers are equipped with knowledge about referral care support and contracted hospitals for effective patient referrals The TPA operates a call center as the main point of contact, offering guidance to individuals in need, while UNHCR's call center can also direct individuals to the TPA for assistance.
As a general rule, governmental hospitals should be prioritized and if not possible, the most cost- effective alternative See Annex 2
Very exceptionally for conditions that cannot be treated in the network, UNHCR may approve care at a hospital outside the network, taking cost into consideration
These are cases when care needs to be provided urgently Usually the beneficiary has suffered a trauma or experienced acute onset of severe symptoms
Typically, the Third Party Administrator (TPA) is engaged when the beneficiary is already receiving care at a network hospital If the beneficiary is not in a network facility, the TPA has specific responsibilities to fulfill regarding their care.
• If the beneficiary has not yet been assessed by a physician, the TPA should provide information about the closest contracted hospitals where an assessment can be obtained;
If a beneficiary qualifies for UNHCR support, the TPA must direct them to a contracted hospital that provides appropriate care This involves confirming bed availability at the facility and, for urgent cases, facilitating access to Lebanese Red Cross/Crescent Ambulance services.
The network hospitals’ responsibilities in regard to the beneficiary seeking urgent health care are:
• To assess and provide initial emergency care;
• If the hospital has the capacity to provide the care that the beneficiary requires, to request approval from the TPA as soon as possible;
If a hospital lacks the capacity to deliver essential care due to insufficient beds or unavailable services, it is crucial to inform the Third Party Administrator (TPA) about the situation This will enable the TPA to assist in locating an appropriate facility that can provide the necessary supported care.
Health care may not be urgently required in certain situations, particularly when the beneficiary has already received a diagnosis and undergone preliminary investigations as an outpatient.
Non-urgent cases typically do not qualify for UNHCR support unless a comprehensive medical report is provided, along with relevant copies of any medical investigations conducted It is the TPA's duty to guide the beneficiary on the necessary documentation and the appropriate delivery locations to ensure the case can be evaluated for eligibility by both the TPA and UNHCR.
Approving initial UNHCR support
In order to approve UNHCR support for care the TPA needs to confirm three things:
1) Whether the beneficiary is a UNHCR PoC;
2) Whether the condition warrants UNHCR support and;
3) Whether the requested treatment is warranted
Beneficiaries must present the hospital and TPA with proof of their status as a Person of Concern (PoC), typically through a UNHCR registration certificate The TPA can verify this information by accessing the UNHCR database of recognized PoCs If the beneficiary does not have the necessary documentation or if validation cannot be confirmed, please refer to section 14.2.
The TPA requires a medical report that includes the beneficiary's diagnosis and supporting copies of relevant investigations It is essential for the TPA to verify that the diagnosis is substantiated by the investigation results and qualifies for UNHCR support as per the guidelines outlined in these SOPs For more information, refer to section 14.
The medical report should outline the proposed investigations and treatments, include the relevant MOPH codes, and provide estimated costs The TPA will evaluate the necessity of these interventions based on standard practices and established SOPs For more information, refer to section 14.
When the above is confirmed the TPA should issue a written approval to the hospital that UNHCR will cover the proposed intervention according to the cost sharing scheme described above
Certain interventions need UNHCR approval (see section 14 and Annex 4a) This includes all interventions that are expected to cost 2900 USD or above
In some cases, a beneficiary may require UNHCR support due to their condition; however, the hospital's recommended intervention may not align with best practices and standard operating procedures For instance, a hospital might propose a surgical intervention when a conservative treatment approach would be more suitable.
In these cases, the TPA and the hospital should have a dialogue about the most appropriate treatment rather than the beneficiary being declined coverage completely
For urgent cases, approval is done while the beneficiary is in the hospital and it is important that it is issued as soon as possible
Beneficiaries who do not seek delivery care and are either unknown to UNHCR or have inactive PoC status should be provided with expedited determination of their PoC status, as outlined in section 14.2.
As soon as the hospital has produced a medical report supported by appropriate documentation the TPA can start the approval process
The TPA can approve relevant investigations or interventions for cases awaiting UNHCR confirmation or fast track PoC status determination, provided these actions address urgent conditions that are life-threatening or could result in permanent severe disability.
Hospitals must contact the Third Party Administrator (TPA) for approval within 24 hours of a beneficiary's arrival; otherwise, they risk non-reimbursement Additionally, if a hospital chooses to proceed with a procedure that the TPA has denied, they will not receive payment for that intervention.
For non-urgent cases, medical reports and PoC status confirmations are conducted on an out-patient basis UNHCR typically does not cover the costs associated with out-patient investigations and does not provide expedited determination of PoC status for these cases.
The TPA plays a crucial role in assisting the beneficiary throughout the investigation process, clarifying any confusion regarding the appropriate type of physician and necessary investigations Multiple interactions between the beneficiary and the TPA may be required to ensure proper guidance Additionally, the TPA can direct the beneficiary to NGOs that offer financial support for these investigations.
Once the beneficiary submits all required documentation to the TPA, there may be a delay before a decision is reached regarding the support for the intervention, often necessitating discussions with the ECC (refer to section 8) The TPA is responsible for keeping the patient informed about the status of their case and any decisions made Once a decision is finalized, the TPA must promptly notify the beneficiary However, any additional details, such as the intervention date, will be provided by the treating facility.
If a case does not qualify for care under the program or if the necessary care is unavailable in the country, it may be suggested for resettlement to another country The TPA delegate must notify UNHCR about these cases to evaluate the possibility of resettlement.
Approving continued UNHCR support
When a beneficiary is admitted, the TPA must monitor the progress of the admission Additionally, if the hospital requires further investigations or interventions, the TPA is responsible for approving these requests.
The TPA is empowered to promptly authorize an investigation or intervention to verify or address an urgent situation that is potentially life-threatening or could result in permanent severe disability.
For long admissions UNHCR needs to be continuously updated about progress of the admission
The TPA is required to send weekly reports starting from the third week of hospitalization for patients in a normal ward, while for intensive care patients, reports must begin from the second week.
The update includes necessary interventions, investigations, prognosis, and planned further actions NICU case reports must adhere to a specific template outlined in section 14.9 If costs are expected to surpass the established ceiling, both the hospital and patient should be promptly informed and advised by the TPA.
If costs are likely to exceed the ceiling, the hospital and patient must be informed and given advice by the TPA in good time
Figure 1: The Referral Process for Urgent Cases ( Non-Deliveries)
TPA CONTACTED FIRST ASSESSMENT INITIAL APPROVAL WITHIN 24-48 HRS DURING HOSPITAL STAY DISCHARGE
TPA monitors the patient throughout their admission and alerts UNHCR if costs near the established ceiling Notifications are also sent at the start of the third week of admission and at the beginning of each subsequent week of hospitalization.
Examining physician determines diagnosis and suggests intervention
If case been referred to UNHCR for medical assessment or for fast track status determination, confirmation should be received within
Depending on outcome, UNHCR support is continued or discontinued
Discharge after follow-up plan has been developed and carefully explained to beneficiary
Medical report and estimate on cost is sent to TPA
Beneficiary produces documents that proves UNHCR recognition as PoC
If new interventions or investigations requested that were not approved initially, TPA needs to approve these
Receipt to beneficiary with his/her share
If beneficiary in need of care and at a network hospital and service is available referral process continues
All urgent life- and limb saving care is approved including investigations to confirm life- and limb threatening conditions
If beneficiary in need of care but not in a network hospital or service not available, TPA identifies a suitable hospital including facilitating transfer if time- critical
If estimated cost >2900 USD or special case TPA refers to UNHCR for confirmation
Final bill for TPA audit
If beneficiary not yet been assessed, TPA informs about network hospitals were to seek care
Figure 2: The Referral Process for Deliveries
DURING PREGNANCY LABOR STARTS FIRST ASSESSMENT INITIAL APPROVAL DURING ADMISSION DISCHARGED TPA CONTACTED ( AT HOSPITAL) Gyn/Obs determines whether need for urgent C- section or if presence of complications
Discharge after hospital provision of birth notification
If non-urgent C- section referral to TPA physician for approval
If normal vaginal delivery or urgent C- section and beneficiary confirmed PoC the TPA approves coverage
If beneficiary at a network hospital and services available referral process continues
If beneficiary not in a network hospital or service not available (e.g no NICU-beds), TPA identifies a suitable hospital including facilitating transfer if time- critical
If new interventions or investigations requested that were not approved initially, TPA need to approve these
Receipt to beneficiary with his/her share
If no active PoC status delivery is not covered Beneficiary produces documents that proves UNHCR recognition as
PoC Interventions for life threatening complications treated as non-delivery case
If urgent C-section Gyn/Obs submits supporting investigation for approval in retrospect
Beneficiary to contact UNHCR reception center to confirm active
If need for elective C-section, treating Gyn/Obs should prepare medical report with supporting investigations
Elective C-section then follows the same process as non-urgent cases
If beneficiary not yet been assessed, TPA informs about network hospitals were to deliver
Figure 3: The Referral Process for Non-Urgent Cases
FIRST CONTACT INVESTIGATION APPROVAL DURING HOSPITAL STAY DISCHARGE
Medical report and estimate on cost is sent to TPA
Discharge after follow-up plan has been developed and carefully explained to beneficiary
Receipt to beneficiary with his/her share
TPA instructs beneficiary about what documentation is needed in order to make a proper eligibility assessment
Final bill for TPA audit
Beneficiary gets the necessary documentation and delivers it to TPA
If diagnosis and intervention according to SOPs and person proven PoC, care is approved If necessary referral to UNHCR for ECC discussion
TPA updates the beneficiary about the process and transmit the outcome of the decision to both beneficiary and health care provider as soon as it is taken
Health care provider schedule intervention and informs the beneficiary
TPA follows patient during admission and notifies UNHCR if costs approach the ceiling
Otherwise at the beginning of the admission’s third week and thereafter beginning of every further week of hospitalization
Beneficiary is admitted If new interventions or investigations requested that were not approved initially, TPA need to approve these
Transfer between hospitals during the same episode of care
Transferring a patient between hospitals is sometimes necessary when the required care is unavailable at the initial facility In these situations, the patient should not incur an additional threshold fee for the second admission, and the total patient share for both admissions must not exceed the cap outlined in section 6.3 If the patient share has already reached this cap at the first hospital, UNHCR will fully cover the costs of the admission at the receiving hospital It is important to note that the cap will be calculated by combining the costs of both admissions.
Discharge and payment
When the treating physician consider it safe, the patient will be discharged If needed, a follow- up plan should be developed and carefully explained to the beneficiary
The hospital must issue a bill for the patient's share along with a receipt immediately after payment is made Additionally, it should provide a separate bill and receipt for any fees paid by the beneficiary for services not covered by UNHCR-supported care, also upon payment.
Hospitals are required to issue birth and death notifications or certificates in the event of births or deaths Before discharge, the Third Party Administrator (TPA) must verify that the beneficiary has received the appropriate and accurate documentation.
The UNHCR-share must be submitted to the TPA for an audit to ensure the care provided is appropriate and approved If the care is not approved, deductions may occur Should a beneficiary be unable to pay their share, the TPA will negotiate with the hospital for a solution, with support from the UNHCR at the field office level.
The TPA in turn sends the audited bills to UNHCR who conducts a further financial and medical audit prior to financial transfer to the TPA who pays the hospital
8 The Exceptional Care Committee (ECC)
Refugees often face serious and complex health issues that require complicated, lengthy, and costly treatments To address these challenges, the UNHCR has formed an Exceptional Care Committee (ECC) to evaluate and determine potential support for these cases.
The Expert Consultation Committee (ECC) is composed of three anonymous medical professionals, including doctors from the UNHCR Public Health Unit (PHU) and representatives from the TPA Operating independently, the ECC convenes biweekly to review and discuss various cases.
The ECC addresses complex and expensive medical cases with uncertain prognoses, such as extensive surgeries and malignant tumor removals Non-urgent cases are evaluated during ECC meetings, while urgent cases are promptly handled through direct communication with relevant ECC members by the PHU BO focal point The ECC determines the level of support for treatment based on specific criteria.
• Necessity and duration of the suggested treatment;
• Feasibility and evidence base of the treatment plan;
The ECC meetings are led by the UNHCR Senior Public Health Officer, with the Assistant Public Health Officer serving as the secretary, tasked with preparation, communication, documentation, and follow-up UNHCR keeps a confidential record of all cases and decisions made during these meetings.
9 Communication between the TPA and UNHCR
To respect patient confidentiality and for documenting purposes, communication between UNHCR and the TPA needs to follow certain rules:
• Medical case management should be restricted between the TPA and the UNHCR public health unit (PHU) in Branch Office (BO) Beirut
Communication between public health teams in field offices and the TPA should be limited to non-medical management issues, including access concerns and complaints regarding hospitals.
• Communication should follow hierarchical lines and communication with TPA head office should be conducted exclusively by PHU BO Beirut
Most communication will primarily occur via email, although urgent matters may be addressed and approved over the phone In such instances, it is essential to follow up with an email summarizing the discussion and the decision made for documentation purposes.
Emails from the TPA regarding patient cases must include sufficient information for decision-making, such as the patient's basic bio data and a medical report with relevant investigation results, adhering to a standard template For further details and examples, refer to Annex 5.
Irregularities noted in the provision of referral care should be brought to UNHCR’s attention Typically, complaints may be raised by refugees, NGO partners, the TPA and hospitals
The TPA is required, as per its agreement with UNHCR, to establish a mechanism for receiving and addressing complaints It is essential that the TPA regularly shares the complaints received and the actions taken with UNHCR.
Refugees, NGO’s and hospitals may also bring the complaint to the nearest UNHCR field office where it will be presented to the public health unit
Complaints should be specific, focusing on a particular case or beneficiary, and must include a detailed account of the events that transpired, mentioning the names of any relevant individuals involved.
Regarding complaints about hospitals, a confidential online form (Hospital Incident Tracking System - HITS) should be filled by concerned UNHCR staff The HITS are compiled by UNHCR PHU
The HITS system plays a crucial role in informing decisions during biannual hospital network reviews by analyzing the number, type, and scale of complaints from various hospitals Actions taken in response to these complaints may include convening meetings with hospital management, issuing warning letters, reporting suspected medical negligence to regulatory authorities, and, as a last resort, terminating contracts.
Complaints on TPA performance brought to UNHCR field offices should be forwarded to the PHU
BO Beirut for assessment and action with the TPA senior management
11 Support provided by NGO partners
Several NGOs provide financial support or facilitate access to services beyond UNHCR assistance These organizations can be approached for cases that fall outside the UNHCR's scope of support.
• Beneficiaries who cannot pay the patient share of hospital bills
• Beneficiaries for whom the cost of treatment exceeds the UNHCR limit of support
• Beneficiaries who suffer from conditions not covered by UNHCR
The referral to an NGO for financial support is normally done by the UNHCR field office, but may also be done by the TPA
NGO support to beneficiaries in the form of payment of hospital bills is a transaction directly between the hospital and the NGO
UNHCR and the TPA can refer suitable beneficiaries to reputable NGOs with established collaborations for health services However, for other NGOs, they can provide information but should refrain from making direct referrals.
For info about NGO’s operating in Lebanon and providing health related services to refugees please see http://data.unhcr.org/lebanon/ under under Inter-Sector Service Mapping
Monitoring and evaluation of the referral care program will be conducted through several mechanisms:
The main data sources for this monitoring purpose are:
Uncertain PoC status
Determining PoC status can be challenging, particularly for children born to PoC mothers with unknown fathers or fathers who deny their paternity Additionally, recognized PoCs may face scrutiny if new information arises that questions their status, such as long-term residents in Lebanon or known combatants It is essential for all such cases to be referred to UNHCR registration centers for accurate status determination and eligibility for support.
In all cases, the decision made by registration is final and if considered PoCs at the time of receiving care, the person is eligible for health care support.
Fast-track determination of PoC status
A person may lack a UNHCR registration certificate or there might be a problem verifying PoC status through the UNHCR database
To facilitate the approval process, issues can be addressed via email communication between the TPA and the regional UNHCR registration office, ensuring that a valid UNHCR registration certificate number is obtained.
Some individuals may not have contacted UNHCR or may have inactive registrations In urgent cases, those in hospitals can qualify for a fast-track process To initiate this, a family member must visit the nearest UNHCR reception center promptly.
During the fast track procedure, the TPA is authorized to approve all essential life and limb-saving care, which will be covered by UNHCR However, if no household member contacts the reception center within 48 hours, or if the individual is determined not to be a Person of Concern (PoC), UNHCR support will cease.
Pregnant beneficiaries receiving standard delivery packages, including vaginal and C-section, cannot fast-track their determination of Person of Concern (PoC) status It is recommended that those not yet registered with UNHCR visit a UNHCR office to confirm their PoC status as soon as they learn of their pregnancy to qualify for financial support Reception centers will prioritize these cases to ensure status confirmation before delivery.
Non urgent/cold cases also do not have the option of fast track status determination
Figure 4: Fast-Trach status determination process and referral pathway
False identities
The TPA must verify that the individual seeking care matches the identity on the UNHCR certificate This can be easily accomplished by requesting an official identity document, such as a driver's license, passport, or national ID If these documents are unavailable, any official or semi-official document containing a photo should be accepted If the individual cannot provide any form of identification, the TPA will take appropriate action.
Page | 24 delegate need to verify the identity visually through photos on RAIS, or using ID verification questioners
UNHCR identity documents may sometimes be misused by individuals other than the intended certificate holders If it is found that a UNHCR certificate is being utilized by someone other than the rightful owner, specific guidelines must be adhered to.
• If the person using the documents is not a PoC (e.g Lebanese or Palestinian) support will immediately be withdrawn for the whole episode of care;
• If the person is a PoC but for some reason lacks documents of his/her own, decision has to be made on a case by case basis;
Wrongful use of identities in deliveries is typically identified when the legitimate owner claims their delivery, revealing that the identity was previously used for another delivery Each case should be evaluated individually; however, generally, if there are no specific extenuating circumstances, such as confusion between IDs in the same household, the support for the current delivery is likely forfeited.
• Cases of false identity should always be reported to UNHCR registration unit.
Beneficiaries with additional protection needs
Certain beneficiaries have additional protection needs and receive additional coverage by UNHCR:
• Victims of torture – covered 100% for care of injuries sustained during torture and any follow up needed requiring referral health care;
Survivors of sexual and gender-based violence receive comprehensive support, including full coverage for injury care, clinical management of rape (CMR), forensic investigations, and necessary follow-up referrals for healthcare services, such as deliveries.
• Patients suffering from primary Severe Acute Malnutrition (SAM) – covered 100% for care related to the malnutrition;
• Psychiatric Patients – covered 90% for acute inpatient psychiatric care
The first two categories must be confirmed by the UNHCR protection department for UNHCR PHU
BO Beirut to forward the cases to the TPA for approval In the case of SGBV, a prerequisite for the
1 See UNFPA/IRC guidelines for what care is included in CMR
100% coverage is that it will contribute to an improvement of the beneficiary’s situation This will be assessed on a case by case basis by protection and PHU together
The TPA is tasked with appointing a focal person to coordinate care for all cases in collaboration with the UNHCR PHU Cases will be referred to selected contracted hospitals or forensic doctors, ensuring they possess the necessary capacity to deliver the required services.
If the TPA come across suspected cases of abuse they should always alert UNHCR that can initiate an investigation by the protection department.
Non-urgent (cold) cases and chronic conditions
Cold cases refer to situations that do not require urgent attention For a cold case to receive support from UNHCR, it must meet two criteria: it should be potentially life- or limb-threatening, and it must be treatable with a single intervention.
Example of cold cases that are eligible for UNHCR support:
• Early stage cancers without spread where a surgical procedure may significantly improve the prognosis
• Myoma leading to severe anemia
• Severe coronary stenosis (without acute coronary symptoms) in need of stent or by-pass
Example of cold cases not eligible for UNHCR support:
Cold case investigations are typically conducted as outpatient procedures and are generally not covered However, exceptions may apply if a beneficiary is deemed eligible for resettlement and requires a specific diagnosis.
The section about specific diagnoses gives further guidance on which cold cases are covered When there are doubts, the TPA should refer the case to UNHCR for final decision
Care for chronic conditions are generally not covered However, if an urgent life-threatening condition arises as a consequence of the chronic condition, UNHCR will cover
• Liver cirrhosis with acute hemorrhage of esophageal varices
• Hematological disorders with need for blood-transfusion
• End stage cancer for which simple procedures can alleviate suffering (draining of ascites or pleural effusion)
Certain chronic cases that are not included in the referral care program may be eligible for resettlement Consequently, it is crucial to forward all rejected cases along with the necessary documentation to UNHCR for evaluation.
Presence of a third party payer
In some cases, a third party, typically an insurance company, is responsible for covering care costs for an individual who has suffered an injury However, the UNHCR generally does not provide support in these situations, unless the third-party coverage is significantly lower than what UNHCR would typically cover In such instances, UNHCR may consider paying the difference.
In certain situations, a third-party payer is expected to be involved, yet none may come forward, such as in work-related accidents or hit-and-run traffic incidents If a third-party payer is unidentifiable or unable to cover treatment costs, UNHCR will continue to provide coverage as usual.
UNHCR will not provide support when the beneficiary is responsible for their own insurance As a result, UNHCR does not cover medical care for an injured driver or vehicle owner involved in an accident, nor for injured passengers who are part of the driver's household.
In the event of an accident, hospitals typically need an Internal Security Forces (ISF) report; however, this should not postpone the approval of essential life-saving care Support may only be delayed if the patient is suspected to be the driver and owner of the vehicle involved in the incident.
ER care
Emergency room (ER) care should be regarded as equivalent to inpatient care, as it addresses urgent conditions that may threaten life or limb It is essential that this type of care, including necessary investigations, is adequately covered.
The determination of coverage for care is unaffected by the beneficiary's admission status Regardless of whether the beneficiary is admitted, the proportion of costs covered is calculated similarly to that of in-patient care.
Obstetric care
UNHCR/TPA has established a standardized fee for a delivery package, encompassing both normal vaginal deliveries and C-sections, across all hospitals in the referral network, although individual hospital charges may differ Importantly, the patient fees remain consistent throughout the network Care within this delivery package is available exclusively to beneficiaries who are recognized by UNHCR and possess an active PoC status.
In cases of severe delivery complications like pre-eclampsia, post-delivery hemorrhage, or sepsis, interventions are treated similarly to other referral care Beneficiaries should be provided with expedited PoC status determination if they are new to UNHCR or have inactive status It's important to note that coverage for this additional care is 75% and does not apply to the $100 threshold.
Elective C-sections require timely approval from the TPA, supported by a medical report and relevant investigations Ultrasound reports must be conducted by a radiologist, not the treating obstetrician Only internationally recognized indications for C-sections are accepted; refer to Annex 4c for the complete list of approved indications.
Urgent C-sections, particularly those indicated for fetal reasons, can be authorized promptly; however, a medical report along with supporting documentation, such as ultrasound and/or CTG, must be submitted afterward Additionally, ultrasounds performed by the obstetrician during non-office hours are acceptable.
UNHCR will not cover for ultrasound investigations in relation to deliveries if they have not been requested by the TPA
Pregnancy-related emergencies not related to deliveries are to be covered in the same way as other referral care
Dilatation and curettage (D&C) is indicated for incomplete and missed abortions, as well as molar pregnancies In non-urgent situations, a confirmed dead fetus must be verified through an ultrasound conducted by a radiologist However, in urgent cases, the ultrasound may be performed by a Gynecologist/Obstetrician.
Neonatal intensive care
UNHCR provides support for neonatal intensive care unit (NICU) care for neonates born at or above 24 weeks of gestation, while those born before 24 weeks and weighing less than 1000 grams are not eligible due to their poor prognosis In cases where the gestational age is 24 weeks or more, care is supported regardless of the neonate's weight It is essential for the TPA to prioritize the needs of the parents in these situations and offer guidance on available support and counseling resources.
When a hospital requests NICU admission, it must submit a medical report along with a completed form detailing the gestational age, birth weight, Apgar score, mode of delivery, multiple gestation, diagnosis for admission, prognosis, and expected costs This information is then sent to UNHCR for approval Meanwhile, the TPA can authorize lifesaving interventions while awaiting UNHCR's confirmation.
Weekly re-evaluation of care in the NICU is essential, including updates on the infant's weight, feeding, breathing, neurological status, current treatment, prognosis, and both incurred and estimated future costs It is also important to indicate whether a TPA physician has assessed the child These medical reports and updates must be communicated to UNHCR, which reserves the right to discontinue support at any time.
1 The child is considered well enough (stable and > 1750 g)
See Annex 4d for further details
Newborns with severe congenital conditions should be referred to UNHCR with a suggestion for intervention The case will thereafter be assessed by the ECC
The ceiling for NICU care is 15,000 USD rather than 10,000 USD.
Implants and transplants
Due to the extreme price range on implants UNHCR have developed certain rules regarding implants
The following are NOT covered:
• Costs of orthopedic implants even though the surgery is covered if indicated by SOPs (i.e fractures);
• Removal of orthopedic implants with the exception of growing children, acute osteomyelitis and if the implants are pins (procedure usually done in ER);
• Insertion and cost of orthopedic prostheses;
• Costs of coronary drug eluting stents (only bare metal stents covered);
• Insertion and cost of defibrillators
• Insertion and cost of pacemakers on a case by case basis;
• Insertion and cost of coronary bare metal stents;
• Insertion and cost of cardiac valve replacements on a case by case basis;
• Insertion and cost of VP shunts (including externally adjustable if 6 months old
✓ Renal lithotripsy for stones that do not pass spontaneously
✓ Prostate surgery when hypertrophy and catheter-demanding obstruction despite medical treatment
✓ Inguinal/femoral hernias in girls < 16 years of age and males < 1 year of age
✓ Thyroid surgery when radiologically proven airway obstruction or toxic and medical treatment failed
✓ Myomas if iron deficiency anemia has required transfusion
✓ Hydatid cysts if serology positive or recommended by infectious disease specialist
Covered cases/interventions that need referral to UNHCR
✓ All cases with estimated cost > 2900 USD
✓ All cases when uncertainty if UNHCR coverage or not
✓ Early stage cancer for which surgery is not complicated and may significantly improve prognosis
✓ Prematurity and other severe neonatal conditions
✓ Congenital conditions in the neonate
✓ Chronic ophthalmological conditions threatening vision in patients < 18 years of age
✓ Hematological urgencies demanding treatment other than transfusion
✓ Psychiatric disorders requiring psychiatric in-patient care
✓ Suspected cases of primary severe acute malnutrition
✓ Suspected cases of abuse (including sexual abuse and torture)
Cases not supported by UNHCR (to be referred to other partners if support available)
✓ Long term treatment for chronic conditions
✓ Cosmetic and reconstructive surgery (including cleft lip/palate surgery)
✓ Non-evidence based, unproven or experimental treatment
✓ Bone marrow and organ transplantation
✓ Chronic ophthalmological conditions in beneficiaries >
✓ Antiviral therapy for hepatitis B and C
✓ Inguinal/femoral hernias in males > 1 year without strangulation
✓ Inguinal/femoral hernias in females > 16 years without strangulations
✓ Umbilical/ventral hernias without strangulation
✓ Undescended testes in boys < 6 months old
B List of orthopaedic cases covered and not covered by UNHCR
The below list is not to be regarded as exhaustive but as guidance
N.B that the below cases all need admission and should be referred to UNHCR for preapproval Simple orthopedic cases (closed fractures that can be reduced in the ER) are also covered but does not need pre- approval
Orthopedic cases supported by UNHCR
• Open fresh fractures with need for surgical intervention
• Closed fractures with significant displacement requiring reduction under anesthesia
• Debridement of soft tissue and bone in open wounds and fractures (Gustilo II and III)
• Acute upper limb nerve injuries including those of the brachial plexus
Orthopedic cases not supported by UNHCR (to be referred to other partners if support available)
✓ Hemodialysis for chronic renal failure
✓ Treatment for late stage cancers (including radiotherapy and chemotherapy)
✓ Surgery for congenital orthopedic conditions
✓ Gallbladder stones without radiological and/or laboratory proof of acute cholecystitis/gall-way obstruction or pancreatitis
✓ Urinary tract stones likely to pass spontaneously (