Diabetes Mellitus/Pre-Diabetes Hypertension Lipid Disorders Stroke Asthma

COPD Schizophrenia Major Depression Dementia Bipolar Disorder

Osteoarthritis BPH Anxiety Parkinson’s Disease CKD (Nephritis/Nephrosis)
Epilepsy Osteoporosis Psoriasis Rheumatoid Arthritis Ischaemic Heart Disease

Chronic Disease
Management Programme

Handbook for
Healthcare Professionals
2018 Includes instructions on use of MediSave for CDMP and
chronic subsidies under Community Health Assist
Scheme (CHAS)
Intentionally left blank
CONTENTS
CHAPTER ONE:
2
The CDMP and CHAS
 Overview
 Clinical Guidelines and Clinical Data Submission

4 CHAPTER TWO:
The Clinical Guidelines
 Enrolling Patients
 Shared Care Programme for CDMP Mental Illnesses (CDMP-MI)
 Guidelines on MediSave Use for CDMP
 Guidelines on Use of CHAS Subsidy for CDMP Conditions
 Disease-Specific Guidelines for the CDMP Conditions

50
CHAPTER THREE:
Registration and MediSave Use
 Policy on MediSave Use
 Registration Process for MediSave for CDMP
 Process of Making a MediSave Claim
 Audit
CHAPTER FOUR:
56
Capture and Submission of Clinical Data
 Commencement of Clinical Data Submission
 Collection and Submission of Clinical Data
 Deadlines for Submission of Clinical Data to MOH

62
CHAPTER FIVE:
User Manual for Clinical Data Submission via CIDC e-Service
 Introduction
 Getting Started
 Clinical Indicators Report Submission
 Patient Details
 Known Medical History
 Clinical Indicators and Assessment
 Attending Physician Information
 Report Submission
 Search Clinical Indicator Reports
 CIDC Clinic Reports
 Troubleshooting
 Fall-Back Procedures
 Contact Information for Queries Related to Clinical Data Collection and Submission

78
CHAPTER SIX:
Frequently Asked Questions
 Clinical Matters
 Registration Matters
 MediSave Claims, Reimbursement, Billing
 Data Submission, Clinical Improvement and Audits
 CHAPTER ONE:
THE CHRONIC DISEASE MANAGEMENT PROGRAMME (CDMP) AND COMMUNITY HEALTH
ASSIST SCHEME (CHAS)

1 Overview

1.1 MediSave for Chronic Disease Management Programme (CDMP)

1.1.1 The CDMP was introduced at the end of 2006, and involves: (a) evidence-based
structured Disease Management Programmes (DMPs1), where applicable and (b) the
option for patients to draw on their MediSave to help reduce out-of-pocket payments
for outpatient treatment required in the management of their chronic diseases.

1.2 Community Health Assist Scheme (CHAS)

1.2.1 CHAS, formerly known as the Primary Care Partnership Scheme (PCPS), was
introduced in Jan 2012 to enable lower- to middle-income Singapore Citizens to
receive subsidies for medical and dental care at CHAS General Practitioner (GP) and
dental clinics.

1.2.2 Since its introduction, chronic conditions under CHAS and CDMP have been kept the
same, allowing CHAS to complement CDMP. Eligible patients with selected chronic
conditions are thus able to enjoy CHAS subsidies, as well as tap on their MediSave for
the outpatient treatment of their chronic conditions.

1.2.3 The Pioneer Generation Package (PGP) was introduced in Sep 2014 to allow all
Pioneers to receive special subsidies under CHAS. This would also help CHAS GPs
provide holistic care for Health Assist (HA)/Pioneer Generation (PG) cardholders under
their care, in line with the vision of “One Family Physician for every Singaporean”.

1.3 Covered Conditions

1.3.1 It is recognised that the treatment of chronic diseases is costly when administered
collectively over a long period. However, CDMP/CHAS will help reduce out-of-pocket
payments and also reduce the barriers for patients to seek medical treatment. With
the inclusion of more chronic conditions under CDMP/CHAS, GPs will be able to take
on a greater role in the management of their patients’ chronic diseases.

1.3.2 The use of CDMP/CHAS will apply to the conditions listed below:

1
Components of disease management include: (a) population identification process; (b) evidence-based practice
guidelines; collaborative practice models to include physician and support-service providers; (d) patient self-
management education; (e) process and outcome management, evaluation, and management; and (f) routine
reporting/feedback loop.

2 Chronic Disease Management Programme

Table 1.1: Chronic Conditions under CDMP/CHAS
Conditions under CDMP/CHAS
Chronic Conditions with 1) Diabetes Mellitus and Pre-Diabetes
Established DMPs 2) Hypertension
(Requiring the reporting of clinical 3) Lipid Disorders
indicators) 4) Asthma
5) Chronic Obstructive Pulmonary Disease (COPD)
6) Chronic Kidney Disease (Nephritis/Nephrosis)

CDMP-Mental Illnesses 7) Schizophrenia

(Requiring participation of 8) Major Depression
clinic/doctor in a Shared Care 9) Bipolar Disorder
Programme)
10) Anxiety

Other Chronic Conditions 11) Stroke

12) Dementia
13) Osteoarthritis
14) Parkinson’s Disease
15) Benign Prostatic Hyperplasia (BPH)
16) Epilepsy
17) Osteoporosis
18) Psoriasis
19) Rheumatoid Arthritis (RA)
20) Ischaemic Heart Disease (IHD)

2 Clinical Guidelines and Clinical Data Submission

2.1 Participating clinics/medical institutions are expected to provide care to patients in

line with the latest MOH Clinical Practice Guidelines (CPGs) and/or best available
evidence-based practice, as well as to track clinical data at patient and clinic/medical
institution level to monitor patient outcome. While participating clinics/medical
institutions will still be required to submit relevant clinical indicators, clinical data
submission is needed for only six of the conditions under CDMP/CHAS. For the other
conditions, essential care components are expected to be documented and may be
subjected to periodic audits.

2.2 Please refer to Chapter Two: The Clinical Guidelines for further details on the essential
care components, indications for referral and specific examples of claimable/non-
claimable items. These are recommended by Subject-Matter-Experts based on best
available medical evidence. The list of clinical indicators to be submitted is detailed in
Chapter Four: Capture and Submission of Clinical Data.

Handbook for Healthcare Professionals 3

 CHAPTER TWO:
THE CLINICAL GUIDELINES

1 Enrolling Patients

1.1 Clinics participating in the CDMP/CHAS are required to provide all the essential care
components detailed in this handbook. The basis for establishing a diagnosis of the
chronic diseases should conform to the prevailing MOH Clinical Practice Guidelines
(CPGs), where applicable.

1.2 The essential care components of each condition are recommended by the Clinical
Advisory Committee appointed by MOH. These components are recommended based
on current available evidence. They can be found in Chapter Two: The Clinical
Guidelines of this handbook.

1.3 To facilitate integration of care across the various settings so that patients are able to
continue and receive the appropriate management of their chronic conditions, MOH
has worked with relevant specialists to develop continuing care guidelines:

a) To identify suitable patients who are stable and can be managed in the
community by their primary care physician rather than in a tertiary setting;
Or
b) To identify patients who are at risk and may benefit from specialist opinion.

1.4 Patients often have one or more of the three common metabolic and cardiovascular
diseases, namely Diabetes Mellitus, Hypertension and Lipid Disorders. For these
patients, they should be enrolled into the respective DMPs according to Annex A (page
10).

1.5 For new diagnosis of Dementia or suspected cognitive impairment, when in doubt, it
is advisable to refer to a geriatrician/psychiatrist/neurologist for confirmation as the
diagnosis carries long term medical and legal implications.

2 Shared Care Programme for CDMP Mental Illnesses (CDMP-MI)

2.1 Mental health conditions, i.e. Schizophrenia, Major Depression, Bipolar Disorder and
Anxiety, are included in the CDMP-MI. Doctors interested in making CDMP/CHAS
claims for the above-mentioned conditions are required to attend training for CDMP-
MI, and participate in Shared Care or GP Partnership Programmes with a public
hospital to ensure that they have sufficient training and confidence in treating patients
with mental health conditions.

2.2 For new diagnosis of mental health conditions, when in doubt, it is advisable to refer
to a psychiatrist, as the diagnosis may carry medical, social and legal implications.

2.3 With effect from 1 Jan 2014, Dementia is no longer a CDMP-MI condition, and
therefore doctors who wish to manage Dementia patients under CDMP/CHAS are no
longer required to participate in the Shared Care or GP Partnership Programme.

4 Chronic Disease Management Programme

3 Guidelines on MediSave Use for CDMP

3.1 Only doctors and clinics/medical institutions which are accredited for MediSave use
and participating in the CDMP can make MediSave claims. Doctors and participating
clinics/medical institutions on the CDMP have to comply with these guidelines.

3.2 From June 2018, package claims will be discontinued under MediSave500, and by
extension, CDMP. Package claims made before 1 June 2018 will still be valid up to one
year from the first date of visit for the package.

3.3 MediSave use is only allowed for outpatient treatments of the approved chronic
conditions in Table 1.1 and/or its associated complications. Clinics must indicate the
relevant MediSave Scheme or Diagnosis of patients in the MediSave Authorisation
Form or Medical Claims Authorisation Form when they make MediSave claims.

3.4 MediSave claims will be accepted only if:

a) The patient is diagnosed to have one of the approved chronic conditions listed
in Table 1.1;
b) The claim must be related to the essential care components in the management
of that specific DMP or for the treatment of the condition and its complications.
The doctor in-charge must clearly document this causal relationship or link
between the condition and its treatment;
c) In this regard, MediSave claims will generally not be allowed for sleeping pills,
slimming pills or erectile dysfunction drugs used for lifestyle purposes;
d) Under certain equivocal circumstances, the auditors will seek further
clarification with the prescribing doctor and decide on acceptance of claim on a
case-by-case basis;
e) Essential care components are to be documented in the doctor’s clinical notes.
Audits may call for essential care components to be submitted at random.

3.5 Certain items including non-evidence-based treatments are not MediSave-claimable.

This is to ensure judicious usage of patients’ MediSave dollars so that they cover
essential care components and medications. A general list of claimable and non-
claimable items is included in Table 2.1 below for reference.

Table 2.1: General List of Claimable and Non-Claimable Items/Services

Claimable Not claimable
 Services delivered at participating  Telehealth services
healthcare institutions
 Relevant investigations (laboratory  Investigations unrelated to the diagnosis,
and radiological) leading to diagnosis management of the disease or its complications
of approved chronic conditions, for  Screening tests, e.g. STD screen, Hepatitis
management of condition and/or screen, Tumour markers
their complications

Handbook for Healthcare Professionals 5

  Investigations for good prescribing
practice to avoid drug-related
complications
 Medications for the management of  Traditional and complementary medicine (e.g.
approved chronic conditions, their herbal medicine, Ayurveda)
complications (e.g. gastro-protectants  Vitamins and/or dietary supplements (except for
when prescribed with NSAIDs), and/or cases with established deficiencies2)
their risk factors (e.g. nicotine  Lifestyle modifying medications (e.g. hair-loss or
replacement therapy for smoking weight-loss medications) except where clinically
cessation) indicated based on prevailing CPGs (e.g. weight-
loss medications for obese patients)
 Non-HSA registered medications
 Off-label use of medications
 Sedatives-hypnotics
 Nursing and allied health services as  Complementary, non-evidence-based therapies
referred by physicians in accordance e.g. massage therapy, chiropractic, homeopathy,
with patients’ integrated care plans, acupuncture
and which fulfil the criteria in para 3.6.  Medical devices, such as blood pressure
monitoring machines, splints, nasogastric tubes
and ambulatory devices (e.g. walking sticks,
wheelchairs)
 Home meal delivery, transport
 Non-healthcare services (e.g. cooking courses,
gym classes)
*More disease-specific examples of claimable and non-claimable items/services can be found in the rest of
Chapter Two: The Clinical Guidelines.

3.6 Support services should meet the following criteria for them to be claimable. A general
list of claimable and non-claimable support services is included in Table 2.2 below for
reference.

a) The support service should be widely regarded as a mainstream healthcare or

support service;
b) There is evidence of the support service being effective in contributing to the
positive management of the chronic disease concerned;
c) The support service should be delivered by a qualified personnel, or where
relevant, an accredited professional3; and
d) The support service provided should be within the scope of practice empowered
under the relevant professional registration Act (if relevant), or otherwise
generally accepted for the professional based on his/her professional
qualifications.

2
In the absence of laboratory tests to definitively diagnose clinical deficiency, other supporting documented
evidence (e.g. patient history, physical exam and/or other lab tests) can be accepted to support the clinical
diagnosis of deficiency.
3
Accredited professionals include doctors, dentists, nurses, physiotherapists, occupational therapists, speech
therapists, diagnostic radiographers, radiation therapists, optometrists and opticians.

6 Chronic Disease Management Programme

Table 2.2: Examples of Claimable and Non-Claimable Support Services
Claimable
 Nursing and related services delivered by registered nurses
o Including nursing care (e.g. diabetic foot wound care, nasogastric tube care),
nurse counselling
 Allied health services
o Therapy services, including physiotherapy, occupational therapy, speech
therapy services delivered by registered AHPs
o Services by non-registered professions specified in the AHP Act, including
podiatry, dietetics, psychotherapy, prosthetics, orthotics
 Other key support services for chronic disease care
o Including diabetic retinal photography, diabetic foot screening, smoking
cessation
Not claimable
 Exercise support
 Stress management
 Sleep management
 Nutritional counselling
 Health coaching
 Cooking courses
 Gym classes

3.7 The maximum amount that can be withdrawn for chronic disease
treatments/attendances taking place from June 2018 and thereafter is $500 per
Medisave account per calendar year.

3.8 Eligible patients can use their personal MediSave account and immediate family
members’ MediSave accounts for payment of their chronic disease treatments.
Immediate family members refer to the spouse, parent or child of the patient. Patients
who are Singapore Citizens or Permanent Residents will also be able to use their
grandchildren’s Medisave accounts to pay for their treatment.

Scenario 1
Mr Lim is a retiree with 2 working children. He is suffering from COPD and has
MediSave from his earlier years of work. Mr Lim can make use of a maximum
of $1,500 of MediSave from his and his children’s MediSave accounts (total
of 3 accounts) every year to pay for his outpatient treatment for COPD.

Scenario 2
The grandmother and parents of Ms Tan are suffering from Diabetes Mellitus.
However, they have no MediSave. Ms Tan can make use of a total of $500
(annual withdrawal limit) of her own MediSave every year to pay for the
outpatient treatments of all 3 of her elders.

Scenario 3
Mdm Haslina is a working adult and has no children. She has Hypertension
and Asthma and can use up to $500 (annual withdrawal limit) from each of

Handbook for Healthcare Professionals 7

 her and her spouse’s MediSave accounts to pay for treatment related to
Hypertension and Asthma.

3.9 Patients may have employer benefits and outpatient insurance that can be used to
pay for outpatient treatments. Bills should be paid using employers’ benefits and any
relevant insurance that the patient may have first, before claiming from MediSave for
the balance.

3.10 In cases where only part of the chronic disease outpatient treatment bill is payable by
employer companies and the patient chooses to use MediSave for the balance of the
bill, clinics would:

a) Follow the current arrangements it has with the employer to seek payment; and
b) Help patients submit the MediSave claim.

4 Guidelines on Use of CHAS Subsidy for CDMP Conditions

4.1 Only doctors and clinics which are participating in the CHAS can make CHAS subsidy
claims.

4.2 Doctors and participating clinics on the CHAS have to comply with the guidelines in
this handbook.

4.3 The guidelines in paras 3.4 to 3.6 on CDMP apply to CHAS claims for CDMP conditions
as well.

4.4 For patients who are eligible for both employee benefits and CHAS, the CHAS subsidies
will apply before the employee benefits.

8 Chronic Disease Management Programme

 5 Disease-Specific Guidelines for the CDMP Conditions

Index 1: The Clinical Guidelines

No. Condition Page
1 Diabetes Mellitus and Pre-diabetes 11
2 Hypertension 15
3 Lipid Disorders 17
4 Asthma 19
5 Chronic Obstructive Pulmonary Disease (COPD) 21
6 Chronic Kidney Disease (Nephritis/Nephrosis) 23
7* Schizophrenia 25
8* Major Depression As above
9* Bipolar Disorder As above
10* Anxiety As above
11 Stroke 28
12 Dementia 30
13 Osteoarthritis 32
14 Parkinson’s Disease 33
15 Benign Prostatic Hyperplasia (BPH) 35
16 Epilepsy 37
17 Osteoporosis 39
18 Psoriasis 41
19 Rheumatoid Arthritis (RA) 44
20 Ischaemic Heart Disease (IHD) 48
* Conditions under the CDMP-MI

9 Chronic Disease Management Programme

 Annex A

Enrolling patients with Diabetes

Mellitus, Hypertension, and/or Lipid
Disorders

Yes
DM? Diabetes Mellitus DMP

No

Yes
HPT? Hypertension DMP

No
Yes
Lip? Lipid Disorders DMP

10 Chronic Disease Management Programme

 Diabetes Mellitus and Pre-diabetes
(Requires reporting of clinical indicators)

Diabetes mellitus is a heterogeneous metabolic disorder characterised by presence of

hyperglycaemia resulting from defects in insulin secretion, insulin action, or both. Chronic
hyperglycaemia is associated with long-term sequelae resulting from damage to various
organs and tissues, particularly the kidney, eye, nerves, heart and blood vessels.

Diagnosing Diabetes

In patients with hyperglycemic crisis, diabetes mellitus can be diagnosed without further
testing.

In patients with typical symptoms, diabetes mellitus can be diagnosed if any one of the
following is present.
1. Casual plasma glucose ≥ 11.1 mmol/L
2. Fasting plasma glucose ≥ 7.0mmol/L
3. 2-hour post-challenge plasma glucose ≥ 11.1 mmol/L

Pre-diabetes is defined by glycaemic levels that are higher than normal, but lower than the
diabetes thresholds. Patients are asymptomatic but the condition puts individuals at higher
risk of developing type 2 diabetes and cardiovascular disease. The pre-diabetic state includes
impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), which can be diagnosed
as follows.

Pre-diabetes Fasting Plasma Glucose (mmol/L) 2-hr Post-load Glucose (mmol/L)*

IFG 6.1 – 6.9 < 7.8
IGT < 7.0 7.8 – 11.0
*2-hour 75g oral glucose tolerance test (OGTT)

HbA1c is not currently recommended as a screening and diagnostic tool for diabetes mellitus.
Its performance in our multi-ethnic population is being evaluated.

Part Ia: Clinical Indicators for Diabetes Mellitus

Essential Care Minimum Remarks
Components Frequency for
Reporting*
Glycated Haemoglobin Twice a year General HbA1c target of ≤7.0%, but target of
(HbA1c) treatment should be personalised (e.g. for elderly)
Blood Pressure Twice a year For patients with type 2 diabetes mellitus who have
Measurement hypertension, an acceptable treatment-initiation
and target blood pressure is <140/80 mmHg
Weight and BMI Twice a year Keep <25kg/m2 (For Asian population, keep BMI
Assessment <23 kg/m2)

11 Chronic Disease Management Programme

 Part Ia: Clinical Indicators for Diabetes Mellitus (continued)
Essential Care Minimum Remarks
Components Frequency for
Reporting*
Lipid Profile Annually All patients should be risk stratified (as recommended in
the Lipids CPG)
Targets of treatment should be personalised by levels of
risk
Nephropathy Annually Good glycaemic control and good BP control with
Assessment Angiotensin Converting Enzyme (ACE) inhibitor or
Angiotensin Receptor Blocker (ARB) preferred to slow
Serum Cr and eGFR, progression of Diabetic Nephropathy
and Urine Albumin-
Creatinine (uACR) Annual screening of serum Cr, eGFR in all patients
Submission of uACR required only for patients with
Nephropathy
Eye Assessment Annually Includes retinal photography and visual acuity
Patients with T1 DM: First assessment within 3-5 years
after diagnosis of diabetes once patient is aged ten years
or older, then annually
Patients with T2 DM: First assessment at diagnosis, then
annually
Foot Assessment Annually Screen for peripheral neuropathy, peripheral vascular
disease, bone, joint, skin and nail abnormalities, and poor
footwear
Smoking Annually Assessment on smoking habits (estimated sticks/day; zero
Assessment for non- or ex-smoker) and provide smoking cessation
counselling
Cardiac At diagnosis Includes baseline ECG
Assessment# before
initiating
medications
*More frequently if clinically indicated
#Non-reportable care component; may be subjected to periodic audits

Part Ib: Clinical Indicators for Pre-diabetes

Essential Care Minimum Frequency Remarks
Components for Reporting*
Screen for CVD Risk Annually To screen for hypertension (BP measurement)
Factors and lipid disorders (lipid panel)
Blood Glucose Test Twice a year For Patients not on Metformin:
(FPG, OGTT, HbA1c) - FPG +/- OGTT to monitor glycaemic control
and screen for diabetes for patients not on
metformin
- HbA1c may be used to monitor glycaemic
control in patients for whom regular FPG +/-
OGTT may not be feasible

12 Chronic Disease Management Programme

Part Ib: Clinical Indicators for Pre-diabetes (continued)
Essential Care Minimum Frequency Remarks
Components for Reporting*
For Patients on Metformin:
- HbA1c is required for patients on metformin
to monitor treatment response. Target HbA1c
<6.5%
- If HbA1c ≥6.5%, withhold metformin for 4-6
weeks and perform FPG +/- OGTT to confirm
T2DM diagnosis
Weight and BMI Twice a year Keep <25kg/m2 (For Asian population, keep
Assessment BMI <23 kg/m2)

Renal Function Annually Yearly renal function test if on Metformin;

Monitoring more frequently if there is evidence of renal
impairment
*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Special Patient Population
 Adults with suspected Type 1 DM
 Children and adolescents with suspected DM (regardless of type)
 Pregnant women or those planning pregnancy who require pre-conception
intensive glycaemic control
 Patients with morbid obesity who are open to the option of intensive weight
management including bariatric surgery
Complications Requiring Active Specialist Management
 Nephrology referral if any of the following:
o Patients with Stage 3b or higher CKD
o Unexpected or rapid decline in renal function
o Difficult management issues (blood pressure, hyperkalaemia control)
o Atypical features (e.g. haematuria, presence of casts in the urine sediment,
presence of renal bruit, nephritic range proteinuria (>3g/day), absence of
retinopathy)
 Ophthalmology referral if any of the following:
o Hard exudates/retinal thickening within one-disc diameter of the fovea
(diabetic macular oedema)
o Severe non-proliferative diabetic retinopathy
o Unexplained drop in visual acuity/eye findings
Early referrals
o Neovascularisation from proliferative diabetic retinopathy
o Pre-retinal and/or vitreous haemorrhage
o Rubeosis iridis (new vessels on the iris)
Urgent referrals
o Sudden loss of vision
o Retinal detachment
o Neovascular glaucoma

Handbook for Healthcare Professionals 13

 Specialist Referral Recommended (continued)
 Foot-care team (podiatry, orthopaedics surgery, vascular surgery) if any of the
following:
o Ulceration, gangrene, severe foot infection
o Suspected acute Charcot’s foot
o Vascular claudication
Consider Specialist Input
High Risk Individuals
 Individuals with or at risk for recurrent severe hypoglycaemia*, diabetic
ketoacidosis (DKA) or hyperglycaemic hyperosmolar state (HHS) regardless of
HbA1c, for specialist input on personalised targets and medication titration to
reduce such risks
 Patients with difficulty achieving satisfactory control of blood glucose and/or other
risk factors
Consider Collaborative Care or Anchoring Care with Primary Care Physician
In patients who
 Are able to achieve satisfactory HbA1c control and/or for
optimisation/management of glycemic control
 Are able to recognise and manage episodes of hypoglycaemia
 Complications of DM are stable, or are under regular review by the appropriate
specialist.
* Severe hypoglycaemia refers to hypoglycaemia where assistance from another person is
required.

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable Items:
Claimables4
 Drugs related to the treatment of DM complications, e.g. Ischaemic Heart Disease,
Chronic Renal Failure, Neuropathic pains (e.g. Amitriptyline and Carbamazepine)
and Peripheral Vascular Diseases (e.g. Pentoxifylline)
 Items involved in drug administration, such as insulin pens, insulin pumps, syringes
and needles dispensed in appropriate quantities, necessary for the patient’s own
use
 Drug therapy for weight management (e.g. orlistat), as an adjunctive to lifestyle
modification and combined with diet and physical activity, when BMI is ≥27.5 kg/m2
 Smoking cessation
 Lancets and glucose test strips for self-monitoring of blood glucose levels for Type
1 diabetes patients and Type 2 diabetes patients on insulin
Non-claimables
 Other items involved in disease monitoring, such as lancing devices, glucometers
and blood pressure monitoring equipment
 Slimming pills and drugs for erectile dysfunction
 Vitamins/supplements such as Vitamin B/B12 (except for cases with documented
deficiency)

4
Providers should also refer to the prevailing Appropriate Care Guide (ACG) on Managing Pre-diabetes for
recommendations on the care to be provided for pre-diabetics.

14 Chronic Disease Management Programme

 Hypertension
(Requires reporting of clinical indicators)

Blood Pressure (BP) levels are continuously related to the risk of cardiovascular disease (CVD).
Even within the normotensive range, people with higher levels of BP have higher rates of CVD.

BP is characterised by large spontaneous variations. The diagnosis of hypertension should be

based on multiple BP measurements taken on several separate occasions. When the systolic
and diastolic BP fall into different categories, the higher category should apply.

Part I: Clinical Indicators

Essential Care Minimum Remarks
Components Frequency for
Reporting*
Blood Pressure Twice a year
Measurement
Weight and BMI Twice a year Keep BMI <25kg/m2. (For Asian population, keep BMI <
23 kg/m2)
Assessment
Smoking Assessment Annually Assessment on smoking habits (estimated sticks/day;
zero for non- or ex-smoker) and provide smoking
cessation counselling
Lipid Profile# At or soon after All patients should be risk stratified (as recommended in
the Lipids CPG)
diagnosis Targets of treatment should be personalised by levels of
risk
Cardiac Assessment# At diagnosis before Includes baseline ECG
initiating
medications
*More frequently if clinically indicated
#Non-reportable care component; may be subjected to periodic audits

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
 Emergency or urgent treatment indicated e.g. malignant hypertension,
hypertensive cardiac failure or other impending complications
 Hypertension difficult to manage e.g. unusually labile BP, hypertension refractory
to multiple drug regimens (3 or more)
 Secondary hypertension i.e. hypertension due to an underlying cause, such as
hyperaldosteronism
 Hypertension in special circumstances e.g. pregnancy, young children
Consider Specialist Input
 Young hypertensive patients who are less than 30 years old
 Patients suspected to have secondary causes of hypertension
Consider Collaborative Care with Primary Physician
 In patients who are able to achieve satisfactory blood pressure control and/or for
optimisation/management of anti-hypertensive medication

15 Chronic Disease Management Programme

 Part III: Claimable/Non-claimable Items
Specific Examples of Claimable/Non-claimable:
Claimable
 For patients with complications of Hypertension, such as Ischaemic Heart Disease,
investigations like 2D Echocardiogram, MIBI scans
 Drug therapy for weight management (e.g. orlistat), as an adjunctive to lifestyle
modification and combined with diet and physical activity, when BMI is ≥27.5 kg/m2
 Smoking cessation
Non-claimable
 Purchase of blood pressure monitoring equipment

16 Chronic Disease Management Programme

Lipid Disorders
(Requires reporting of clinical indicators)

Lipid disorders (dyslipidaemia) play a major role in the pathogenesis of coronary heart disease.
It is a modifiable cardiovascular risk factor that may be inherited or acquired.
Hypercholesterolaemia, mixed (combined) dyslipidaemia and hypertriglyeridaemia are the
three commonest dyslipidaemias.

Common causes of secondary dyslipidaemia should be excluded in any patient presenting

with dyslipidaemia.

Part I: Clinical Indicators

Essential Care Minimum Frequency Remarks
Components for Reporting*
Lipid Profile Annually All patients should be risk stratified (as recommended in the
Lipids CPG)
Targets of treatment should be personalised by levels of risk
Smoking Annually Assessment on smoking habits (estimated sticks/day; zero for
non- or ex-smoker) and provide smoking cessation
Assessment counselling
Serum Before starting Especially when the statin dose is increased
or when combination therapy is initiated
transaminases# statins and 8-12
weeks after; Stop the statin / fibrate if patient is symptomatic
Annually
Serum creatine Before starting Look out for rapid increase in creatine kinase post–initiation
or increase of statin or fibrate. Stop the medication if the CK
kinase# statins and 8-12 is three times ULN) or at about 800 IU/L (whichever is lower)
weeks after;
Annually
*More frequently if clinically indicated
#Non-reportable care component; may be subjected to periodic audits

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Referral to A&E
 If the ALT/AST is ≥ 5X ULN (upper limit of normal) or if patient is clinically
ill/decompensating
Referral to Endocrinologist
 Initiation of rosuvastatin at doses higher than 20mg
Referral to Gastroenterologist
 For clinical presentation of acute hepatitis
Consider Specialist Input
Consider Referral to Endocrinologist
 Triglyceride level more than 4.5mmol/L despite dietary changes and maximum
tolerated drug therapy
 Target parameters not achieved despite maximal drug therapy
 Definite or possible familial hypercholesterolemia on Simon Broome Trust
diagnostic criteria (or other validated criteria)

Handbook for Healthcare Professionals 17

 Consider Referral to Gastroenterologist
 Pre-treatment transaminases are 1.5 to 3 times above normal range
 Persistently high transaminases (at least 3 times above normal range) during statin
therapy or when statin has been stopped
Consider Collaborative Care with Primary Physician
In patients who are
 Able to achieve satisfactory lipid control and/or for optimisation/management of
lipid disorder medication

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Claimable
 Omega 3 fish oils, only for patients with severe hypertriglyceridemia (e.g.
TG >4.5mmol/L [400mg/dL]) where fibrates alone may not adequately lower the
markedly elevated TG levels
 Drug therapy for weight management (e.g. orlistat), as an adjunctive to lifestyle
modification and combined with diet and physical activity, when BMI is ≥27.5
kg/m2
 Smoking cessation
Non-claimable
 Red yeast supplements (Hypocol) and Co-enzyme Q10

18 Chronic Disease Management Programme

Asthma
(Requires reporting of clinical indicators)

Asthma is a chronic reversible airway disorder that is common in people of all ages. It can be
severe and may be fatal. Asthma may present with cough, wheezing, and unexplained
dyspnoea and chest tightness. Symptoms are often transient, may be persistent and tend to
be worse at night or in the early mornings.

Asthma symptoms may be precipitated or aggravated by upper respiratory tract infections,

cigarette smoke, environmental haze, exercise, drugs (e.g. aspirin, NSAIDs, ß-blockers, ACE
inhibitors), pets and occupational exposure to triggers.

Spirometry is the most reliable test of reversible airway obstruction. Improvement in FEV1 of
more than 12% is significant. Peak expiratory flow rate is a less reliable test but patients may
improve by 15% or more in response to inhaled bronchodilators, or present with diurnal
variability for PEFR of > 10% in adults and >15% in children.

Part I: Clinical Indicators

Essential Care Components Minimum Frequency for Remarks
Reporting*
Asthma Control Test (ACT) Twice a year Recommended for assessment of
control at every visit, for patients 4
score years and above. For those below 4
years old, proper documentation of
symptom frequency and severity (e.g.
daytime or night-time symptoms,
whether symptoms affect the patient’s
sleep, feeding, activities) from patient’s
carer is required
Self-Management At diagnosis  Check for compliance to treatment
 Provide and review patient’s Written
Education (with Written Asthma Action Plan when there is any
Asthma Action Plan)# change in treatment
 Inhaler technique assessment
Smoking Assessment Annually Assessment on smoking habits
(estimated sticks/day; zero for non- or
ex-smoker) and provide smoking
cessation counselling
*More frequently if clinically indicated
#Non-reportable care component; may be subjected to periodic audits

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Control: Failure to achieve asthma control despite optimal treatment
 Patients who are currently on or recently stopped daily oral corticosteroid therapy
to achieve control
 History of near-fatal asthma requiring intubation and ventilation
 Severe asthma requiring step 4 care and yet experiencing exacerbation despite
compliance to treatment

Handbook for Healthcare Professionals 19

 Specialist Referral Recommended (continued)
Control: Failure to achieve asthma control despite optimal treatment
 Poorly controlled asthmatics with ≥ 2 hospitalisations and/or requires ≥ 2 courses
of burst therapy with oral corticosteroids in the past one year
Confusing Sign and Symptoms
 Suspected occupational asthma will require further diagnostic determination of
the industrial trigger agent
 Patient with atypical signs and symptoms such as unilateral wheeze to exclude
other tracheobronchial pathology
Children
 Has poor asthma control with frequent urgent care needs
 Is below 3 years with atypical features e.g. failure to thrive and/or are not
responding to low dose inhaled steroid (BUD < 200 mcg/day BDP/ FP < 100 / day)
 Requires high dose steroids. (BUD / FP > 400mcg/day or BDP > 200mcg/day)
 Is on prolonged inhaled steroid therapy for more than 6 months and remains
symptomatic
 Suffered from a severe acute attack and requires prolonged or repeated oral
steroids for control
 Diagnosis is uncertain
Consider Specialist Input
Co-Morbidity
 Concurrent heart failure which may complicate management
 Psychiatric disease or multiple psychosocial problems, including the use of
sedative
 Concurrent active GERD which may mimic asthma
Consider Collaborative Care with Primary Care Physician
In patients who
 Require symptom monitoring and optimisation/management of asthma
medications
 Require social support to cope with their disease

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Claimables
 Investigations for management of the disease and complications (e.g. CXR,
pulmonary function tests, allergy tests)
 Investigations for good prescribing practice to avoid drug-related complications
(e.g. serum theophylline)
 Items involved in drug administration, such as spacers and accompanying masks
dispensed in appropriate quantities, necessary for the patient’s own use
 Smoking cessation
Non-claimables
 Investigations unrelated to the diagnosis or follow-up of Asthma
 Non-evidence based investigations such as hand-held spirometry

20 Chronic Disease Management Programme

Chronic Obstructive Pulmonary Disease (COPD)
(Requires reporting of clinical indicators)

Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous disorder characterised by

airflow obstruction that is not fully reversible. The airflow limitation is usually both
progressive and associated with exposure to noxious particles or gases. Smoking is by far the
most important risk factor.

Patients may present with chronic productive cough and breathlessness. Acute exacerbations
of COPD may require hospitalisation. The prevalence of COPD is highest after age 50, and is
generally higher in men than women.

A pulmonary function test/spirometry result will establish the diagnosis of COPD for
CDMP/CHAS purposes.

Part I: Clinical Indicators

Essential Care Minimum Frequency for Remarks
Components Reporting*
COPD Assessment Annually
Test (CAT) Score
Smoking Annually Assessment on smoking habits (estimated sticks/day;
zero for non- or ex-smoker) and provide smoking
Assessment cessation counselling
Influenza
Annually
Vaccination
Weight and BMI Annually Nutritional intervention should be considered in all
COPD patients with BMI <18.5kg/m2 or significant
Assessment involuntary weight loss (>10% during the last 6 months
or > 5% in the past month)
Self-Management At diagnosis  Educate on what to do during acute exacerbations;
#  Inhaler technique assessment
Education
Spirometry# At or soon after diagnosis
*More frequently if clinically indicated
#Non-reportable care component; may be subjected to periodic audits

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Severe Cases
 Rapidly progressive course of disease
 Acute exacerbation of COPD not responsive to therapy
 Development of new symptoms (e.g. haemoptysis) or new physical signs (e.g.
cyanosis, peripheral oedema)
 End stage COPD (requiring long term oxygen therapy or considering surgery)

Handbook for Healthcare Professionals 21

 Consider Specialist Input
Severe or Complex Cases
 Severe COPD (i.e. FEV1<50% predicted)
 Frequent exacerbations (e.g. two or more a year) despite compliance to treatment
Consider Collaborative Care with Primary Care Physician
In patients who
 Require follow-up monitoring for onset of new symptoms, decreased effort
tolerance, adherence to medication and smoking cessation advice

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Claimables
 Items involved in drug administration, such as spacers and accompanying masks
dispensed in appropriate quantities, necessary for the patient’s own use
 Investigations for good prescribing practice to avoid drug-related complications
(e.g. serum theophylline)
 Smoking cessation
Non-claimables
 Medications not approved for COPD, including mast cell stabilisers (e.g. Ketotifen)
 Investigations unrelated to the diagnosis or follow-up of COPD
 Non-evidence based investigations such as hand-held spirometry
 Purchase of oxygen tanks, nebulisers or other home nursing equipment

22 Chronic Disease Management Programme

Chronic Kidney Disease (Nephritis/Nephrosis)
(Requires reporting of clinical indicators)

Haematuria and proteinuria are the hallmarks of glomerular disease. In addition,

hypertension, impaired renal function and fluid retention can be present to varying extents.
The nature and severity of the underlying glomerular injury often dictate the nature and
severity of these symptoms.

Conditions covered include (a) Chronic Glomerulonephritis (presenting as nephritic or

nephrotic syndromes), (b) Nephropathies (e.g. secondary to underlying diabetes or other
conditions) and (c) Chronic Kidney Diseases (with or without known underlying aetiology).

Part I: Clinical Indicators

Essential Care Minimum Frequency Remarks
Components for Reporting*
Blood Pressure Twice a year ACE-I and ARBs should be used for BP control
when proteinuria is present
Measurement
Renal Function – eGFR or Annually If eGFR is submitted, it should be using the MDRD
formula;
Serum Creatinine Serum Creatinine to be submitted for calculation
(for calculation) if lab does not generate MDRD-
eGFR
Urinary Protein – Urine Annually
Protein Creatinine Ratio
(uPCR) or Albumin-
Creatinine Ratio (uACR)
*More frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Significant Proteinuria
 Urine protein > 1 g/day (or its equivalent i.e. uPCR>100mg/mmol or
ACR>70mg/mmol)
Persistent Haematuria
Declining Renal Function
 eGFR < 45 ml/min/1.73 m² or rapid decline (> 5 ml/min/1.73 m² per year)
Difficult BP Control
 BP>150/90mmHg despite 3 anti-hypertensive medications at maximal doses
Consider Collaborative Care with Primary Care Physician
In patients who
 Are able to reach individualised BP target reached based on severity of
glomerulonephritis and proteinuria
 Have stable renal function (decline <30% over 4-month follow-up)
 Are not hyperkalaemic

Handbook for Healthcare Professionals 23

 Part III: Claimable/Non-Claimable Items
Specific Examples of Claimable/Non-Claimable:
Claimables
 Pre- and post-dialysis investigations
 The treatment of complications, such as renal osteodystrophy, as well as
complications of dialysis
 Drug therapy for weight management (e.g. orlistat), as an adjunctive to lifestyle
modification and combined with diet and physical activity, when BMI is ≥27.5 kg/m2
 Smoking cessation
Non-claimables
 Supplements such as Iron/Calcium/Vitamin D (except in cases with documented
deficiency)
 Unrelated investigations, e.g. myeloma panels
 Transplant-related investigations and/or procedures

24 Chronic Disease Management Programme

 CDMP-Mental Illness
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Schizophrenia is a mental illness characterised by delusions, hallucinations, disorganised

speech, disorganised or catatonic behaviour, and negative symptoms. Other psychotic
disorders and organic brain disorders should be excluded.

Major Depression is a mental illness characterised by low mood, anhedonia, significant

weight loss/gain, insomnia, psychomotor agitation or retardation, fatigue or loss of energy,
feeling of worthlessness or inappropriate guilt, diminished ability to think or concentrate, and
recurrent thoughts of suicide. Other milder psychiatric conditions, organic conditions or
prescription medication-induced depression should be excluded.

Bipolar Disorder is a mental illness characterised by episodes of mania and depression. During
acute episodes, there may be either an elevation of mood with increased energy and activity,
or a lowering of mood with decreased activity. Manic episodes may last between two weeks
and five months (with median duration of four months), while depressive episodes may last
longer.

Anxiety is an emotion experienced by everyone in everyday life to perceived threats, but it is

considered to be a disorder when it is of greater intensity and/or duration than would be
expected in the given circumstances, affects daily life, gives rise to unexplained physical
symptoms, or leads to avoidance of situations and places.

In order to provide greater support (e.g. professionally as well as drugs) for family physicians
managing patients with mental illness, family physicians are required to participate in Shared
Care or GP Partnership Programmes with Restructured Hospitals before CDMP/CHAS claims
can be made.

*Anxiety disorders claimable under CDMP/CHAS are General Anxiety Disorder, Panic Disorder,
Phobic Anxiety Disorders, Obsessive-Compulsive Disorder, and Post-traumatic Stress Disorder.

Part I: Clinical Indicators

Applicable to all Mental Illnesses
Essential Care Minimum Frequency* Remarks
Components
Clinical Global Annually CGI assessment for
 Severity (Scores 1-7)
Impression (CGI) Scale  Clinical improvement (Scores 1-7)
*1 indicates “normal/no mental illness” or
“very much improved”
Consultations for CDMP Twice a year Consultation includes assessment for
symptoms, response and adherence to
Mental Health medications, psychosocial interventions, risk
of harm to self or others and general physical
health
*More frequently if clinically indicated

25 Chronic Disease Management Programme

 Part II: Consideration for Collaborative Care
a) Schizophrenia
Specialist Referral Recommended
Initial assessment
 Assessment, diagnosis and initiation of treatment, when in doubt
High Risk Individuals
 Risk of violence to self or others
 Unstable/uncontrolled symptoms, e.g. recent hospitalisation within last 6 months
Consider Specialist Input
Special Patient Population
 Pregnant, paediatric or geriatric patients
 Forensic or medico-legal issues involved
Complex Cases
 Unexpected changes in symptomatology
 Drug-related complications
 Treatment resistance
Consider Collaborative Care with Primary Care Physician
Follow up
 Monitoring for adherence, early signs of relapse, medication side effects and
medication adjustment
 Optimisation of metabolic risk factors (especially for patients on anti-psychotics)

b) Major Depression and c) Bipolar Disorder

Specialist Referral Recommended
Initial assessment
 Assessment, diagnosis and initiation of treatment, when in doubt
High Risk Individuals
 Patients experiencing manic episode
 Risk of violence to self or others, especially patients with suicidal risk
 Having psychosis (hallucinations or odd beliefs)
 Symptoms of catatonia (refusing to talk, eat or drink)
 Need for hospitalisation
Failure of treatment
 Failure of one or two trials of medication
 Need for augmentation or combination therapy (e.g. with mood stabilisers,
psychotherapy)
 Need for specialised treatment (e.g. Electroconvulsive treatment)
Consider Specialist Input
Special Patient Population
 Pregnant or paediatric patients
 Forensic or medico-legal issues involved

26 Chronic Disease Management Programme

 Consider Specialist Input (continued)
Complex Cases
 Complicated by medical, psychiatric and/or psychosocial co-morbidities, including
addiction disorders and substance abuse
 Unstable/uncontrolled symptoms, e.g. recent hospitalisation within last 6 months
Consider Collaborative Care with Primary Care Physician
Follow up
 Monitoring for adherence, early signs of relapse, medication side effects and
medication adjustment
 Optimisation of metabolic risk factors (especially for patients on anti-psychotics)

d) Anxiety
Specialist Referral Recommended
Initial assessment
 Assessment, diagnosis and initiation of treatment, when in doubt
High Risk Individuals
 Patients with suicidal risk
 Unstable/uncontrolled symptoms, e.g. recent hospitalisation within last 6 months
Failure of treatment
 Marked functional impairment, disruptive personality disorders
 Failure of one or two trials of medication
 Need for hypnotics (e.g. Benzodiazepines, Zolpiclone), and/or formal
psychotherapy
Consider Specialist Input
Special Patient Population
 Paediatric patients
Complex Cases
 Complicated by medical, psychiatric and/or psychosocial co-morbidities, including
addiction disorders and substance abuse
Consider Collaborative Care with Primary Care Physician
 Monitoring for adherence, early signs of relapse, medication side effects and
medication adjustment

Part III: Claimable/Non-Claimable items

Applicable to all Mental Illnesses
Specific Examples of Claimable/Non-Claimable:
Claimable
 Treatments such as Psychological Therapy, Electro-Convulsive Therapy (ECT),
Occupational Therapy, Physiotherapy and Speech Therapy
Non-claimable
 Sedatives-hypnotics

Handbook for Healthcare Professionals 27

 Stroke
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Cerebrovascular disease (CVD) is a heterogeneous disease. There are clear pathological sub-
types – transient ischaemic attack (TIA), cerebral infarction, primary intracerebral
haemorrhage and subarachnoid haemorrhage – with over 100 potential underlying causes. It
may affect men and women of any age, and can manifest as a minor episode lasting less than
24 hours (TIA), to a major life threatening or disabling event, and even death. Survivors of
strokes may make a complete recovery, or have varying degrees of disability.

Part I: Clinical Indicators

Essential Care Component Minimum Remarks
Frequency*
Thromboembolism Risk As clinically indicated Evaluate for atrial fibrillation, cardiac
murmurs, fasting glucose and need for anti-
Assessment thrombotic therapy
Rehabilitation Need Baseline
Assessment
Blood Pressure Twice a year
Measurement
Lipid Profile Annually All patients should be risk stratified (as
recommended in the Lipids CPG)
Targets of treatment should be personalised
by levels of risk
Smoking Assessment Annually Assessment on smoking habits (estimated
sticks/day; zero for non- or ex-smoker) and
provide smoking cessation counselling
*More frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
 New (suspected) onset of TIA or Stroke
 New onset of atrial fibrillation or cardiac murmurs requiring further evaluation
Consider Collaborative Care with Primary Care Physician
In patients who are
 On long term anticoagulation (i.e. warfarin) for dose adjustment
 On anti-platelet therapy and require continued management of their cardiovascular
risk factors

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Claimable
 Treatment of stroke complications such as depression
 Drug therapy for weight management (e.g. orlistat), as an adjunctive to lifestyle
modification and combined with diet and physical activity, when BMI is ≥27.5
kg/m2
 Smoking cessation

28 Chronic Disease Management Programme

Non-claimables
 Supplements such as Vitamin B/B12 (except for cases with documented deficiency)
 Dietary supplements (e.g. Glucerna, Ensure)
 Purchase of medical equipment such as blood pressure monitoring equipment,
walking aids, wheelchairs and other home nursing equipment
 Nootropics (e.g. piracetam)

Handbook for Healthcare Professionals 29

 Dementia
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Dementia is a neurodegenerative disease that is characterised by progressive impairment of

cognitive function. As the disease increases in severity, patients may experience some or all
of the following: memory loss, language impairment, disorientation, changes in personality,
difficulty with activities of daily living, self-neglect, neuropsychiatric symptoms and out of
character behaviour.

Part I: Clinical Indicators

Essential Care Component Minimum Remarks
Frequency*
Assessment of Memory Annually For patients on cognitive enhancers, objective
documentation of memory assessment with a
bedside cognitive screening instrument (e.g.
Mini-Mental State Examination) must be
performed.
Assessment of Mood and Annually Enquiring about mood and behaviour and
initiating appropriate non-pharmacological
Behaviour and/or pharmacological treatment where
appropriate
Assessment of Social Annually Assessment and referral to care coordinator,
medical social worker or appropriate
Difficulties and Caregiver community services may be required
stress (if any)
Functional Needs Annually To assess home safety, driving safety, falls,
functional decline and swallowing difficulties
Assessment
*More frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
 Young onset Dementia (YOD) i.e. onset before the age of 65
 Patients who decline rapidly (based on feedback from caregiver and clinical
impression)
 Patients in whom diagnosis of Dementia is uncertain
 Uncontrolled behavioural and neuropsychiatric symptoms despite trial of
pharmacological / non-pharmacological interventions
Consider Collaborative Care with Primary Care Physician
In patients who
 Have minimal behaviour problems or behaviours that are well controlled with
modest doses of medications
 Are stable with minimal coping issues in both patient and caregiver
 Have mild/moderate dementia and are keen to drive will require a driving
assessment by the Occupational Therapist

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Non-claimables

30 Chronic Disease Management Programme

 Off-label/non-HSA registered/non-evidence-based medications or therapies (e.g.
NSAIDs, COX2 inhibitors and Prednisolone) for prevention of cognitive decline
 Dietary supplements (e.g. Vitamin E, Ginkgo) or traditional medications/therapies
(e.g. aromatherapy or massage therapy)

Handbook for Healthcare Professionals 31

 Osteoarthritis
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Osteoarthritis typically affects older people. The diagnosis can be made clinically based on
history and physical examination, with laboratory and radiologic investigations selectively
undertaken to exclude inflammatory arthritis, secondary osteoarthritis and non-articular
causes of joint pain.

Part I: Clinical Indicators

Essential Care Minimum Remarks
Components Frequency*
Joint Pain and Function Annually
Prescription and Annually In the form of a directed or supervised muscle
strengthening or aerobic exercise programme
Review of Exercise Plan Can be undertaken by physiotherapist
Weight and BMI Annually Weight reduction should be advocated for patients
with BMI of ≥23 kg/m2. Obese patients with BMI ≥30
Assessment kg/m2 should be referred to a medically-supervised
weight reduction programme
Activities of Daily Living Annually Referral to physiotherapy/occupational therapy
assessment for assisted devices made, should ADL be
(ADL) Assessment impaired

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Lack of Response to Conservative Treatment
 Unsatisfactory improvement of pain, stability or function despite adequate
conservative (non-pharmacological and pharmacological) treatment
Consider Collaborative Care with Primary Care Physician
In patients who
 Require long-term follow up of mild to moderate disease
 Pain is adequately controlled with analgesics and physiotherapy
 Have severe disease with multiple co-morbidities, not a suitable candidate for
surgical management

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Claimables
 Intra-articular steroid injections
 Investigations related to the management (e.g. X-ray, MRI) and complications (e.g.
diagnostic knee aspiration after intra-articular steroid injections) of Osteoarthritis
 Drug therapy for weight management (e.g. orlistat), as an adjunctive to lifestyle
modification and combined with diet and physical activity, when BMI is ≥27.5 kg/m2
Non-claimables
 Off-label/non-HSA registered medications, dietary supplements or alternative
therapies (e.g. Glucosamine, Calcium, and Acupuncture and Chiropractic)
 Intra-articular viscosupplementation, oral steroids and therapeutic knee
aspirations, due to weak evidence

32 Chronic Disease Management Programme

Parkinson’s Disease
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Parkinson’s disease is an age-related chronic progressive neurodegenerative disorder. In its

early stages, Parkinson’s disease usually presents with asymmetric tremor, bradykinesia and
rigidity. In later stages, non-motor features, such as autonomic dysfunction, falls, sleep
disturbances, and cognitive abnormalities, appear. While the disease may occur in a younger
population, the average age of onset is in the early to mid-60s.

For the purpose of CDMP/CHAS, this is defined to include Parkinson’s disease and
Parkinsonism (excluding Drug-induced Parkinsonism).

Part I: Clinical Indicators

Essential Care Minimum Remarks
Components Frequency*
Review of Diagnosis Annually The diagnosis would be reviewed regularly and reassessed if there
are atypical features (e.g., falls at presentation and early in the
disease course, poor response to levodopa, symmetry at onset,
rapid progression to Hoehn & Yahr stage 3 in 3 years, lack of
tremor or dysautonomia)
Review of Treatment Annually Review and discussion with regard to medical and surgical
treatment options, as well as need for rehabilitative therapies
(physiotherapy, occupational therapy and speech therapy)
Review of Annually Assessment for cognitive impairment, psychiatric disorders (e.g.
depression, psychosis), autonomic dysfunction (e.g. constipation,
Complications incontinence, orthostatic hypotension), falls, sleep disorders, and
medication-related side effects
*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
Complicated or Atypical Parkinsonism
 Young-onset (≤ 55 years old) Parkinson’s disease
 Atypical Parkinsonism
 Parkinson’s disease complicated by dyskinesia, dystonia, myoclonus or gaze palsies
Consider Specialist Input
Complicated or Atypical Parkinsonism
 Patients who do not respond to levodopa or dopamine agonists
 Patients with cognitive impairment or neuropsychiatric dysfunction
 Family history of Parkinson’s disease
Consider Collaborative Care with Primary Physician
In patients who
 Require long-term follow up and medication

Chronic Disease Management Programme 33

 Part III: Claimable/Non-Claimable Items
Specific Examples of Claimable/Non-Claimable:
Claimable
 Laxatives for bedbound/wheelchair bound patients
Non-claimable
 Dietary supplements or traditional medications/therapies (e.g. CoEnzyme Q10)

34 Chronic Disease Management Programme

Benign Prostatic Hyperplasia (BPH)
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Benign Prostatic Hyperplasia (BPH) is among the commonest urological problems in the
elderly. Patients present with acute retention of urine, or lower urinary tract symptoms, such
as hesitancy, poor stream, intermittency, and feeling of incomplete voiding. Irritative
symptoms are nocturia, frequency and urgency.

Important differential diagnoses are carcinoma of the prostate and bladder, occult
neuropathic bladders due to ageing, diabetes mellitus or Parkinson’s disease.

Part I: Clinical Indicators

Essential Care Minimum Remarks
Components Frequency*
Review of Lower Urinary Annually Recommended tool for assessment of LUTS is the -
International Prostate Symptom /Quality of Life
Tract Symptoms Score
Clinical Examination – Initial assessment Abdominal examination includes assessment for a
palpable bladder. Rectal examination to assess
Abdominal and Digital size, consistency and regularity of prostate
Rectal Exam
Co-Morbidity Initial assessment
Assessment (includes
medication review)
Urine Labstick or Initial assessment Screen for haematuria, pyuria and glycosuria
Microscopy

*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
 Hard and/or irregular prostate
Consider Specialist Input
 Retention of urine, palpable bladder and/or high residual urine
 Urinary incontinence and/or other persistent bothersome symptoms
 Haematuria
 Proven urinary tract infection
 Bladder stones
Consider Collaborative Care with Primary Physician
In patients whose
 Symptoms well controlled, require long term follow up and assessment

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimable/Non-Claimable:
Claimable
 Investigations related to the management of Benign Prostatic Hyperplasia and
complications (e.g. PSA tests)

Handbook for Healthcare Professionals 35

 Non-claimables
 Phosphodiesterase-5 inhibitors
 Testosterone tests
 Dietary supplements or traditional medications/therapies (e.g. Saw palmetto
extract)

36 Chronic Disease Management Programme

Epilepsy
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Diagnosis of Epilepsy
Epilepsy is a chronic disorder of the brain characterised by recurrent seizures. Seizures are
episodes of involuntary shaking which may involve a part of the body (partial) or the entire
body (generalised), sometimes accompanied by loss of consciousness and control of bowel or
bladder function, and result from excessive electrical discharges in a group of brain cells and
may occur in different parts of the brain.

The diagnosis of epilepsy in adults should be established by a neurologist who will have better
access to the investigative tools necessary to confirm the diagnosis including classifying the
epilepsy syndrome.

The diagnosis of epilepsy in children and adolescents should be established by a paediatric

neurologist.

Part I: Clinical Indicators

Essential Care Components Minimum Frequency* Remarks
Seizure Frequency Annual
Seizure Type Annual
Seizure Free Duration Annual
*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Consider Specialist Input
 Inadequate seizure control (e.g. in general less than 1 year between seizures while on
anti-epileptic drug (AED))
 Potential withdrawal of AEDs in patients with more than one AED
Consider Collaborative Care with Primary Care Physician
 Able to achieve good seizure control (i.e. seizure-free for at least 1 year)
 Titration and review of AEDs by the family physician according to a weaning regimen
prescribed by the specialist for patients who have been seizure-free for at least 2 years

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimables/Non-Claimables:
Claimables
 Investigations (except genetic testing) to evaluate etiology, e.g. EEG and MRI brain
 Investigations to monitor epilepsy and related disease complications, e.g. full blood
count, renal panel, liver function test, vitamin D and calcium levels
 Ketogenic diet initiated by a specialist in neurology or paediatrics for children who
have drug resistant epilepsy (i.e. child has failed to become seizure free / stay
seizure free with adequate trials of two AEDs) and where medically necessary as
treatment for those who are on enteral feeding or predominately on milk feeds

Handbook for Healthcare Professionals 37

 Part III: Claimable/Non-Claimable Items
Specific Examples of Claimables/Non-Claimables (continued):
Claimables
 Investigations to monitor/guide treatments, e.g. AED blood levels for detection of
non-adherence, suspected toxicity, adjustment of phenytoin dose, HLA-B 1502
genotyping for susceptibility to carbamazepine allergy
 Investigations to monitor complications of treatments (including ketogenic diet)
 Supplements in specific situations where there is documented deficiency or where
medically indicated (e.g. supra-physiological doses of pyridoxine, pyridoxal
phosphate and folinic acid for vitamin-responsive seizures, and carnitine for those
on sodium valproate and at risk of secondary carnitine deficiency)
Non-Claimable
 Genetic testing for epilepsy
 Nootropics (e.g. piracetam)

Table 2.3: List of Claimable Investigations for Patients on Ketogenic Diet

At baseline and on routine follow-up if indicated:
Full blood count Urine organic acids
Renal panel Urine ketones
Liver panel Magnesium
Lipid panel Serum amino acids
ECG Lactate
AED level Ammonia
Betahydroxybutyrate EEG
Random urine calcium & creatinine Renal ultrasound

38 Chronic Disease Management Programme

Osteoporosis
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Diagnosis of Osteoporosis
Osteoporosis is a ‘progressive systemic skeletal disease characterised by low bone mass and
microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility
and susceptibility to fracture’.5

Common sites of fracture are the vertebral bodies of the spine, the hip, the forearm and the
proximal humerus.

Osteoporosis should be diagnosed based on Dual Energy X-Ray Absorptiometry (DXA) of hip
and spine, and/or previous fragility fracture. Currently, the use of methods other than hip
dual energy X-ray absorptiometry to diagnose osteoporosis is not recommended.

Individuals found to have osteoporosis should have relevant clinical, laboratory and
radiological assessments to exclude diseases that mimic, cause or aggravate osteoporosis, so
that appropriate management may be implemented.

Table 2.4: WHO definitions based on BMD

BMD T-score (S.D.) Definition
≥ -1 Normal
< -1 to > -2.5 Low bone mass (osteopenia)
≤ -2.5 Osteoporosis
≤ -2.5 and a fragility fracture Severe or established osteoporosis

Part I: Clinical Indicators

Essential Care Minimum Frequency* Remarks
Components
DEXA scan At least once every 2 BMD readings at femoral neck, total hip and lumbar
spine.
years6 Minimal measurement: BMD of femoral neck.
WHO Fracture Risk Annual http://www.shef.ac.uk/FRAX/tool.jsp to access
FRAX score calculator
Assessment Tool (FRAX
Score)
*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Consider Specialist Input
 Male or pre-menopausal female patients

5
Consensus development conference: prophylaxis and treatment of osteoporosis. Am J Med. 1991
Jan;90(1):107-10.
6
When BMD has normalised, frequency of DEXA scans should be based on patient’s osteoporosis risk (viz low,
moderate or high) as defined in Osteoporosis Self-Assessment Tool for Asians (OSTA).

Handbook for Healthcare Professionals 39

 Consider Specialist Input (continued)
 Patients with / suspected of secondary osteoporosis (e.g. disproportionately low Z-
scores, long-term steroid use, co-existing endocrine diseases such as
hyperparathyroidism, hypogonadism, hypercortisolism and hyperthyroidism)
 Patients with structural or congenital bone condition
Consider Collaborative Care with Primary Care Physician
 Patients with primary osteoporosis and on bone protective agent
 Patients with secondary osteoporosis who are stable and compliant with medications

Part III: Claimable/Non-Claimable Items

Specific Examples of Claimables/Non-Claimables:
Claimables
 Oral bisphosphonates and evidence supported therapies, e.g.
o IV Zoledronic acid, raloxifene, s/c teriparatide, and denosumab where medically
indicated, such as for patients at high risk of fractures and unable to comply with
oral bisphosphonates
o Vitamin D analogues (e.g. alfacalcidol and calcitriol) for glucocorticoid-induced
osteoporosis
 Investigations related to the management of osteoporosis (DEXA scans and blood tests
for levels of calcium, vitamin D, thyroid stimulating hormone, parathyroid hormone)
 Calcium and vitamin D for patients with established deficiencies or those who are
unlikely to meet the respective daily requirements
Non-Claimable
 Testosterone and hormone replacement therapy (HRT)

40 Chronic Disease Management Programme

Psoriasis
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Diagnosis of Psoriasis
Psoriasis is a chronic inflammatory skin disease that typically follows a relapsing and remitting
course. Plaque psoriasis presents with well-delineated erythematous, scaly plaques, with or
without pustules.

Typical sites of involvement are the scalp, behind the ears or in the concha, on extensor
surfaces (i.e. elbows and knees), and the sacral area and natal cleft.
It is associated with characteristic nail changes (more than 5 pits on any nail, onycholysis or
subungual hyperkeratosis) and joint pains, especially fingers showing dactylitis or sausage
shaped joints.

Psoriatic arthritis is an inflammatory polyarthritis that may develop in up to 30% of people

with psoriasis. There is no definitive test to diagnose psoriatic arthritis. Some associated
conditions are achilles tendinitis and plantar fasciitis.

Part I: Clinical Indicators

Essential Care Minimum Remarks
Components Frequency*
Assessment of psoriatic Annual Monitor for joint pain. If present, to proceed with
recommended tool for assessment – Psoriasis
arthritis Epidemiology Screening Tool (PEST) and refer to specialist
Body Surface Area (BSA) Annual Use patient’s palm as an estimate of 1% BSA and consider
referral to specialist if BSA > 10%
affected by psoriasis
*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
 Psoriatic arthritis
 Patients with rash that cannot be controlled with topical therapy
 Patients with such severity or type of psoriasis potentially requiring systemic agent
or phototherapy
Consider Specialist Input
 Patient with “unstable” rash i.e. rapid and/or considerable change in psoriasis (e.g.
rapid BSA extension, frequent flares, plaque psoriasis fluctuating between
pustulation and remission)
 Patients with generalised pustular psoriasis or erythroderma
Consider Collaborative Care with Primary Care Physician
In patients who
 Have stable/low disease activity
 Are on long term methotrexate# (with specialist review every six months to one
year)

Handbook for Healthcare Professionals 41

 # In the management of these patients, primary care physicians should be guided by detailed
management plans set out by the specialist (who should oversee the monitoring of the
lifetime dose for patients, as well as perform drug titration if necessary).

Figure 1: Decision tree for collaborative care

42 Chronic Disease Management Programme

Part III: Claimable/Non-Claimable Items
Specific Examples of Claimables/Non-Claimables:
Claimables
 Phototherapy
 Systemic non-biologic therapy, e.g. Methotrexate, Cyclosporine, Acitretin
 Biologics treatment
 Baseline investigations before starting systemic and biologics therapy (e.g. full blood
count, renal panel, liver panel, chest radiograph, hepatitis B and C screening)
 Routine investigations for patients on oral systemic and biologics therapy
 Investigations to monitor joint involvement
 Topical applications where prescribed:
o Standard moisturisers (e.g. aqueous cream, urea cream and white soft paraffin)
and
o Corticosteroid creams/ointment (e.g. hydrocortisone, betamethasone valerate,
betamethasone dipropionate)
o Coal tar, salicylic acid, olive oil
o Vitamin D analogues
Non-Claimable
 Over-the-counter products (e.g. moisturisers, emollients, bath solutions) purchased
without a prescription

Table 2.5: List of Claimable Investigations for Patients who are presently on or initiating
Oral Systemic and Biologic Therapy
At baseline: On routine follow-up:
Full blood count For patients on MTX:
Liver panel Full blood count
Renal panel Liver panel
Chest x-ray Creatinine (periodically)
Hep B and C screening Liver fibroscan/Magnetic resonance elastography
TB-spot (for pre-biologic) if indicated
Liver fibroscan/Magnetic resonance
elastography if indicated For patients on Cyclosporin:
Renal panel
Before starting Acitretin Liver Panel
Fasting lipids
For patients on Acitretin:
Before starting Cyclosporine Liver Panel
Fasting lipids Fasting lipids
Serum magnesium

Handbook for Healthcare Professionals 43

Rheumatoid Arthritis (RA)
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Diagnosis of Rheumatoid Arthritis (RA)

Rheumatoid arthritis is a chronic inflammatory autoimmune disease of unknown etiology. It
is characterised by inflammatory pain and stiffness of synovial joints, with progressive joint
destruction if untreated. It is associated with extra-articular manifestations (such as sicca
symptoms, interstitial lung disease, and vasculitis), and systemic comorbidities (such as
cardiovascular disease and osteoporosis).

A rheumatoid arthritis flare is characterised by worsening disease activity, commonly

accompanied by raised ESR or CRP that requires a change in therapy. It must be distinguished
from non-inflammatory causes of worsening joint pain, swelling, and septic arthritis.

Patients who meet one of the following classification criteria will be eligible for claims under
Rheumatoid Arthritis.

1) Patients who meet the 1987 ARA criteria for rheumatoid arthritis or the 2010
ACR/EULAR Diagnostic criteria for rheumatoid arthritis.
2) Established rheumatoid arthritis with characteristic features such as joint swelling
and deformity
3) Early rheumatoid arthritis previously diagnosed and followed up by a
rheumatologist.
4) Juvenile rheumatoid arthritis previously diagnosed and followed up by a
rheumatologist.

Spondyloarthritis/Ankylosing Spondylitis, Adult Onset Still's Disease are not claimable under
the CDMP Rheumatoid Arthritis.

Part I: Clinical Indicators

Essential Care Components Minimum Remarks
Frequency*
Assessment of RA Disease Annually Number of tender / swollen joints, CRP or ESR;
Measures of disease activity must be obtained and
Activity documented regularly, as frequently as monthly for
patients with high/moderate disease activity, or less
frequently (at least at 6 month intervals) for patients in
sustained low disease activity or remission.
*more frequently if clinically indicated

Part II: Consideration for Collaborative Care

Specialist Referral Recommended
 Patients requiring new initiation of DMARD therapy
 Patients with RA flares requiring either high dose (e.g. prednisolone >10mg/day) or long
term (≥6 months) glucocorticoid therapy (which should be accompanied by appropriate
dose adjustment of DMARDs)
 Patients with extra-articular manifestations of RA
 Patients on biologic DMARD therapy

Chronic Disease Management Programme 44

 Paediatric patients with six weeks or more of persistent joint swelling, and joint pain
Consider Specialist Input
 Patients who develop active disease (1 or more swollen and/or tender joints, high
ESR/CRP) while on collaborative care
Consider Shared Care with Primary Care Physician
 Patients deemed to be in DMARD-free remission
 Patients deemed to have quiescent/low disease activity (no swollen and/or tender
joints, ESR/CRP within normal range) for at least 3-6 months under a specialist’s care
 Patients on (non-biologic) DMARD therapy at maintenance dosage

Handbook for Healthcare Professionals 45

 Figure 2: Decision tree for collaborative care

46 Chronic Disease Management Programme

Part III: Claimable/Non-Claimable Items
Specific Examples of Claimables/Non-Claimables:
Claimables
 Investigations for the monitoring of the disease and related complications (e.g. full
blood count, renal panel, liver function test, CRP, ESR, X-rays)
 Non-biologic DMARD therapy
 Biologic DMARD therapy where medically indicated (e.g. where disease is inadequately
controlled with non-biologic DMARD therapy)
 Investigations performed prior to the initiation of DMARD (biologic & non-biologic)
therapy, e.g. hepatitis B and C serology, T-spot TB
 Baseline eye screening, and annually after five years of drug institution, for patients on
hydroxychloroquine
 Anti-inflammatory agents (e.g. NSAIDS, selective COX-2 inhibitors and glucocorticoids)
as adjunct treatments
Non-Claimable
 Serum Rheumatoid Factor (RF), anti-CCP Antibody testing and other investigations
done prior to and not leading to diagnosis of disease

Handbook for Healthcare Professionals 47

Ischaemic Heart Disease (IHD)7
(While clinical indicator submission is not currently required, clinicians are required to
document these assessments in case notes)

Ischaemic heart disease (IHD)/ coronary artery disease (CAD) includes stable and unstable
angina pectoris, myocardial infarction (MI), current complications following MI, and plaques
visualised in the coronary arteries without ischaemia.8

IHD results when coronary artery plaque develops and reduces the oxygen supply to the
myocardium. Early intervention is required to prevent disease progression and recurrent
cardiovascular events. This includes lifestyle modification and medical therapy as indicated.

Evidence to support a diagnosis of IHD (for purposes of claims under CDMP) could include:
a) Past history of symptoms, prior diagnosis of IHD, current symptoms and/or
investigation findings (e.g. electrocardiogram (ECG), stress test, angiography)
consistent with cardiac ischaemia
b) Post-acute myocardial infarction (AMI)
c) Prior percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG)

Part I: Clinical Indicators (see Appendix for references)

Essential Care Component Minimum Remarks
Frequency*
Lipid Profile Annually Target LDL <2.1mmol/L as patients with
IHD/CAD are in the “very high risk” group

Blood Pressure Twice a year

Measurement
Smoking Assessment Annually Assessment on smoking habits (estimated
sticks/day; zero for non- or ex-smoker) and
provision of smoking cessation counselling

Weight and BMI Assessment Twice a year Keep BMI <25kg/m2. (For Asian population,
keep BMI < 23 kg/m2)

Diabetes Screening Annually or once Screening should be carried out every three
years for those with normal glucose
every three years, as tolerance, and annually for those with
the case may be impaired fasting glycaemia (IFG) or impaired
glucose tolerance (IGT). Refer to Diabetes
Mellitus chapter for diagnostic criteria
Renal Function Monitoring Especially for patients on ACE inhibitors.
Serum Cr and eGFR†, and Urine Albumin-
Creatinine (uACR) may be considered.

*More frequently if clinically indicated

7
Includes coronary artery disease for purposes of claims under CDMP.
8
Non-ischaemic heart diseases, such as non-ischaemic cardiomyopathy, congenital heart diseases, arrhythmias
and valvular defects, are not covered.

Chronic Disease Management Programme 48

Part II: Consideration for Collaborative Care
Specialist Referral Recommended
 Emergency or urgent treatment indicated, e.g. unstable angina, myocardial
infarction, and acute decompensated heart failure
 Suboptimal control of IHD risk factors despite lifestyle modification and optimised
medical therapy, e.g. lipids and blood pressure
Consider Collaborative Care or Anchoring Care with Primary Physician
 Stable IHD, e.g. stable angina, history of MI but otherwise stable condition

Part III: Claimable/Non-claimable Items

Specific Examples of Claimable/Non-claimable:
Claimable
 Investigations for evaluation of IHD severity, monitoring of progression, detection
of complications and guidance on further treatment, e.g. ECG, stress test,
transthoracic echocardiography, cardiac CT angiogram, and cardiovascular risk
factor monitoring such as lipid profile
 Smoking cessation
 Cardiac Rehabilitation
Non-claimable
 Monitoring devices for cardiovascular risk factors, e.g. blood pressure monitoring
equipment, glucometer and strips

Handbook for Healthcare Professionals 49

 CHAPTER THREE:
REGISTRATION AND MEDISAVE USE

1. Policy on MediSave Use

1.1. The primary purpose of MediSave is to help Singaporeans afford costly hospitalisation
bills. For chronic conditions, early detection and good management help patients avoid
subsequent costly hospitalisations. To bring about better health outcomes, MOH has
allowed MediSave to cover selected chronic conditions in the outpatient setting.

1.2. From 1 July 2014, the $30 deductible applicable for each outpatient CDMP bill using
MediSave has been removed. Nonetheless, to ensure prudent use of MediSave funds,
two safeguards remain in place under the CDMP:

a) Co-payment: A co-payment of 15% will apply on each outpatient CDMP bill;

and
b) Annual withdrawal limit: An annual withdrawal limit of $500 per MediSave
account applies9. This will be reset on 1 January of each year.

Example:
For a CDMP bill of $100, the patient pays $15 out-of-pocket. The remaining
$85 can be claimed from MediSave.

1.3 Only doctors and clinics/medical institutions which are accredited for MediSave use and
participating in the CDMP can make MediSave claims for patients. To make claims for
Mental Illnesses10 (i.e. Schizophrenia, Major Depression, Bipolar Disorder and Anxiety),
doctors also need to attend training for CDMP-MI and participate in a Shared Care or
GP Partnership Programme with a public hospital 11 . Doctors with the qualifications
below are exempted from having to attend training for CDMP-MI:

a) GPs on the existing Mental Health GP Partnership Programme;

b) Doctors with MMed(FM), GDFM or on the Register of Family Physicians need
not attend CDMP Mental Health training if the mental health training modules
of these programmes include all the conditions in CDMP Mental Illnesses.
c) Doctors with Family Medicine (FM) training who had 3 months posting at
psychiatric departments at the various Restructured Hospitals from May 2007;
d) Doctors (Family Physicians, Family Doctors, Medical Officers) who had 6
months posting at psychiatric departments at the various Restructured
Hospitals; OR
e) Holders of the Graduate Diploma in Mental Health.

9
The withdrawal limit was raised from $400 from June 2018.
10
Dementia will not be considered a mental illness under the CDMP as of 1 Jan 2014, and therefore physicians
who wish to manage Dementia under CDMP are not required to participate in the Shared Care Programme.
11
The Shared Care Programme was meant to provide specialised support (e.g. from psychiatrists and mental
health trained nurses, as well as supply of drugs for mental illness) to primary care doctors and ensure that they
have sufficient training and confidence in treating patients with mental health conditions.

50 Chronic Disease Management Programme

2. Registration Process for MediSave for CDMP

2.1. Clinics That Wish to Participate in the CDMP

2.1.1. To be in the CDMP, both the clinic/medical institution and its doctor(s) have to register
with and be accredited by MOH. Upon accreditation, the doctors can then make
MediSave claims for their patients.

2.1.2. An outline of the registration and accreditation process is provided in Table 3.1.

Table 3.1: Registration and Accreditation Process (MediSave for CDMP)

Steps

Clinics submit E-Application form to MOH

↓
Interested clinics submit documents to CPF Board and NCS
↓
Clinic representative(s) attends training session (process, IT and Medisave guidelines)
↓
MOH approves the participation of the clinics
↓

NCS configures the system

CPF Board prepares Deed of MOH issues letters of
setup & issues token
Indemnity with clinics approval to clinics
cards

↓
Doctors submit accreditation forms to MOH
↓
Effective date of participation in the CDMP by clinics

2.2 Registration of Clinic/Medical Institution with MOH

2.2.1 To join the CDMP, clinics/medical institutions will need to fulfil the following criteria:

a) Be able to make MediSave claims for patients through the online MediClaim
system12, the MOH Healthcare Claims Portal (MHCP) system, or other Clinic
Management Systems such as ClinicAssist;
b) Sign a Deed of Indemnity with CPF Board; and
c) Submit clinical data to MOH.

2.2.2 To make claims for patients through the online MediClaim system, clinics/ medical
institutions need to have:

a) A MediClaim User account;

b) A Security Token Card (Incurs a non-refundable cost of $191.20 (inclusive of 7%
GST and delivery fee) for two to three years of use. The subsequent token is
priced at $171.20.);

12
Clinics which are not ready to make claims through MediSave e-service could opt to submit claims via other
Clinic Management Systems such as ClinicAssist.

Handbook for Healthcare Professionals 51

 c) A Personal Computer/Laptop with the following configuration:
(i) CPU Pentium III and above,
(ii) Memory (RAM) Minimum of 256MB,
(iii) Operating System Windows XP,
(iv) Browser Internet Explorer 6.0, and
(v) Internet connection;
d) GIRO arrangement with CPF Board for MediSave payments to be credited into
the clinic/medical institution’s bank account; and
e) Attended training to process MediSave claims.

2.2.3 To make claims for patients through the online MHCP system, clinics/medical
institutions need to have:

a) A CorpPass account
b) A Personal Computer/Laptop with the following configuration:
(i) 1 gigahertz (GHz) or faster processor,
(ii) 4GB RAM or above,
(iii) 10GB of free space in HDD,
(iv) 1366 x 768 display resolution for optimum viewing,
(v) 10 Mbps Internet bandwidth,
(vi) Browser Internet Explorer 10.0 or above (Chrome, Firefox and Safari
browsers are also supported),
(vii) Adobe Acrobat Reader,
(viii) Microsoft Excel 2007 and above; and
(ix) Internet connection
c) GIRO arrangement with CPF Board for MediSave payments to be credited into
the clinic/medical institution’s bank account; and
d) Attended training to process MediSave claims.

2.2.4 Clinics/medical institutions interested in joining the CDMP will need to submit the
following forms to MOH:

a) E-Application for Clinics to Participate in the MediSave for CDMP (by MOH);
and
b) Direct Authorisation Credit Form (by CPF Board).

The E-Application website can be accessed via:

https://www.mediclaim.moh.gov.sg/mmae/OverviewApplication.aspx

2.2.5 Clinic/medical institution staff who will be making MediSave claims are required to
attend a free half-day training session on MediSave claims process, MediSave use
guidelines and use of the MediClaim system.

2.2.6 Clinics/medical institutions participating in the CDMP will be subjected to:

a) Clinical quality checks conducted by MOH on patients who make MediSave

claims through the clinics/medical institutions;
b) Professional medical audits conducted by MOH on MediSave claims; and/or

52 Chronic Disease Management Programme

 c) Operational audits conducted by CPF Board on MediSave claims.

2.3 Registration of Doctor with MOH

2.3.4 Doctors practising at accredited clinics/medical institutions need to register with MOH
to participate in the CDMP before they can make MediSave claims for their patients.

2.3.5 Interested doctors can submit an E-Application to participate in the CDMP. The
website is: https://www.mediclaim.moh.gov.sg/mmae/OverviewApplication.aspx
Registration for MediSave accreditation of doctors needs to be renewed every 2 years.

2.3.6 Registered doctors will be audited by MOH and CPF Board on the clinical outcomes and
MediSave claims of their patients.

3 Process of Making a MediSave Claim

A typical process of making a MediSave claim for a patient is described below:

3.1 What to convey to patient or immediate family members who wish to use MediSave:

a) The treatment components

b) The cost of treatment
c) Estimated amount that can be claimed from MediSave, and
d) Out-of-pocket cash payment that the patient needs to make

3.2 Administrative Procedure

a) Each MediSave account holder will need to sign a MediSave Authorisation

Form or a Medical Claims Authorisation Form to authorise the CPF Board to
deduct his/her MediSave funds for the treatment of the patient. The
authorisation can be made on a per treatment basis or over a period of time13.
Authorisations over a period of time will stand until revoked in writing.
b) Clinic/medical institution staff should witness the identity and the signature by
the patient or account holder. Clinic/medical institution staff should also verify
relationships declared, where possible.
c) Clinics/medical institutions are to submit the MediSave claims electronically to
CPF Board for processing via the MediClaim System.

3.3 If the patient is deemed to be mentally incapacitated (see definition of mentally

incapacitated person below), his donee/deputy or immediate family members would
need to authorise the use of the patient’s own MediSave. The doctor in charge would
need to certify on the relevant part of the form that the patient is mentally
incapacitated.

Definition: A mentally capacitated person either:

13
Authorisation can be for a period of 3, 6 or 12 months, or for an open-ended length of time subject to
revocation in writing.

Handbook for Healthcare Professionals 53

 a) has a medical report from a psychiatrist declaring that the patient is
permanently mentally incapacitated; or
b) is determined by a doctor, at the material time, to be unable to make a decision
for himself. An inability to make a decision is when a patient is unable to:
(i) Understand the information relevant to the decision;
(ii) Retain that information relevant to the decision;
(iii) Use or weigh that information as part of the decision making process;
and
(iv) Communicate his decision (by any means).

3.4 Payment will be made daily to MediSave-accredited clinics/medical institutions via

InterBank Giro (IBG) on the 3rd working day after the approval date of the MediSave
claims.

Where a clinic/medical institution has made an over-claim or unauthorised deduction

from MediSave, it will have to refund the amount deducted to the MediSave account. The
clinic/medical institution will have to pay the interest lost by individuals if it is the
clinic’s/medical institution's error. The interest will be computed at the prevailing CPF
interest at the time of the adjustment.

3.5 From June 2018, package claims will be discontinued under CDMP. Package claims made
before 1 June 2018 will still be valid up to one year from the first date of visit for the
package. Where such package lapses or is cancelled with remaining treatments,
clinics/medical institutions should refund the unused MediSave amount to the
appropriate payer.

3.6 Clinics submit Medisave claims electronically.

4 Audit

4.1 All MediSave claims for CDMP conditions may be subjected to audit. The CPF Board may
carry out regular audits of the participating clinic’s/medical institution’s records for
MediSave claims. There are 2 types of audits for the MediSave claims:

a) Operational audit: This audit looks at the operational aspect of making

MediSave claims such as proper documentation and the completion of Medical
Claims Authorisation Form;
b) Professional audit: This audit looks at treatments and investigations
administered for each MediSave claim to determine if it is related to the
diagnosis.

4.2 MediSave claims for all CDMP conditions may be subject to audit. Prior notice will be
given to identify the cases to be audited. The following documents may be required for
the audit:

a) Hard copies of Claim Forms submitted electronically,

b) MediSave Authorisation Forms / Medical Claims Authorisation Forms,

54 Chronic Disease Management Programme

 c) Itemised bills/Payment records (detailing consultation charges, individual drug
charges, DRP, nursing charges, other services),
d) Photocopies of identification papers (where necessary),
e) Case records of the patient for the visits which were claimed (For claims on the
complications of the approved chronic diseases, doctors have to document the
causal relationship. For packages, please indicate dates of visits which are
claimed),
f) Investigation/Test reports where available e.g. HbA1c results, lipid results,
g) Prescription records, and
h) Evidence supporting diagnosis e.g. documentation in case records or
laboratory reports.

4.3 Routine clinical data submission will only be required for Diabetes Mellitus/Pre-diabetes,
Hypertension, Lipid Disorders, COPD, Asthma, CKD (Nephritis/Nephrosis). Please note
that in case the MediSave claim includes treatment for complication(s) due to the
chronic disease, the doctor would need to document clearly the causal relationship
between the approved chronic condition and the complication(s) which arose from it.

4.4 Clinics/medical institutions or doctors found guilty of wrong claims will be required to
refund the amount to the affected MediSave accounts. Each time the doctor is found
making wrong claims for his/her patients, he/she will be issued a warning letter.
Repeated infringements by a doctor can lead to suspension of the MediSave
accreditation of the doctor.

Handbook for Healthcare Professionals 55

 CHAPTER FOUR:
CAPTURE AND SUBMISSION OF CLINICAL DATA
1 Commencement of Clinical Data Submission
Data submission should commence at the patient’s first visit to the doctor for selected
CDMP/CHAS conditions. These are Diabetes Mellitus/Pre-diabetes, Hypertension,
Lipid Disorders, Asthma, COPD, CKD (Nephritis/Nephrosis).
1.1 The quality of patient care for these six chronic conditions will be evaluated
according to whether the relevant process and care components have been met
as listed below:
Table 4.1: List of Clinical Indicators for CDMP/CHAS (For Submission)
Chronic Condition Care Components Per Year14
Diabetes Mellitus  Two blood pressure measurements
 Two bodyweight measurements
 Two haemoglobin A1c (HbA1c) tests
 One serum cholesterol level (LDL-C) test
 One smoking habit assessment
 One eye assessment
 One foot assessment
 One nephropathy assessment (Additional indicators for patients
with nephropathy will follow that of Nephritis/Nephrosis)
Pre-diabetes  One blood pressure measurement
 Two bodyweight measurements
 Two or more blood glucose tests (FPG, OGTT, HbA1c) as
appropriate15
 One serum cholesterol level (LDL-C) test
 One nephropathy assessment (if on metformin)
Hypertension  Two blood pressure measurements
 Two bodyweight measurement
 One smoking habit assessment
Lipid Disorders  One serum cholesterol level (LDL-C) test
 One smoking habit assessment
Asthma  Two Asthma Control Test (ACT)16 scores
 One smoking habit assessment
COPD  One smoking habit assessment
 One bodyweight measurement
 One COPD Assessment Test (CAT) score
 One influenza vaccination
CKD (Nephritis/  Two blood pressure measurements
Nephrosis)  One renal function – creatinine and/or eGFR
 One urine protein – urine protein : creatinine ratio

14
‘Per year’ refers to 12 months from the first visit of the patient for the chronic condition(s).
15
Refer to Clinical Guidelines for Pre-diabetes (p11-14) for more details.
16
This is only applicable for patients aged 4 and above. For patients aged 4 to < 12 years, please use
the Childhood ACT, and for those aged 12 years and above, the ACT.

56 Chronic Disease Management Programme

1.2 Although data submission is not required for the remaining conditions, clinicians
are advised to manage according to best clinical practices and document
essential care components as listed below:

Table 4.2: List of Clinical Indicators for CDMP/CHAS (Routine Data Submission not
required)
Chronic Condition Minimum Clinical Indicators (Per Year) 17
Schizophrenia  Two consultations for CDMP Mental Health
 One Clinical Global Impression (CGI) Scale for each
item (severity, improvement)
 Blood test for fasting glucose and fasting lipids18
Major Depression  Two consultations for CDMP Mental Health
 One Clinical Global Impression (CGI) Scale for each
item (severity, improvement)
Bipolar Disorder  Two consultations for CDMP Mental Health
 One Clinical Global Impression (CGI) Scale for each
item (severity, improvement)
Anxiety  One Clinical Global Impression (CGI) Scale for each
item (severity, improvement)
Stroke  Two blood pressure measurements
 One serum cholesterol level (LDL-C) test
 One smoking habit assessment
 One clinical thromboembolism risk assessment
 One rehabilitation need assessment
Dementia  Documentation of:
i. Assessment of mood and behaviour
ii. Assessment of social difficulties and caregiver
stress (if any)
iii. Assessment of functional needs assessment
 Two consultations for CDMP Dementia
 For patients on cognitive enhancers, documentation
of objective assessment of memory (MMSE or
CMMSE testing or other validated instruments)
Osteoarthritis  One Joint function assessment
 One bodyweight measurement
 One exercise and/or weight loss plan (if indicated)
 One Activities of Daily Living (ADL) assessment
Parkinson’s Disease  One Unified Parkinson’s Disease Rating Scale (for
falls)
 One Schawb and England Activities of Daily Living
Scale
 One review of diagnosis

17
‘Per year’ refers to 12 months from the first visit of the patient for the chronic condition(s).
18
Only for patients with Schizophrenia on atypical antipsychotic medications.

Handbook for Healthcare Professionals 57

 Chronic Condition Minimum Clinical Indicators (Per Year) 17
BPH  One International Prostate Symptom Score (I-PSS)
 One Abdominal examination/Digital rectal
examination
 One Urine dipstick test
Epilepsy  One seizure frequency assessment
 One seizure type assessment
 One seizure free duration assessment
Osteoporosis  At least one DEXA scan every 2 years
 One WHO Fracture Risk Assessment Tool (FRAX
Score)
Psoriasis  One psoriatic arthritis assessment
 One Body Surface Area (BSA) percentage assessment
Rheumatoid  One RA disease activity assessment
Arthritis
Ischaemic Heart  Two blood pressure measurements
Disease  Two bodyweight measurements
 One diagnostic diabetes test for those with impaired
fasting glycemia or impaired glucose tolerance, or
one diagnostic diabetes test for those with normal
glucose tolerance
 One serum cholesterol level (LDL-C) test
 One smoking habit assessment
 One nephropathy assessment

2 Collection and Submission of Clinical Data

2.1 The collection of clinical data can be carried out by:

a) Manually recording the clinical data on a hardcopy template (Annex B,
page 54-55). Please note that for submission purposes the data will
subsequently have to be keyed in via the online CIDC e-Service (see
Chapter Five: User Manual for e-Service Clinical Data Submission) or the
MHCP system (see the MHCP User Guide available in the MHCP Resource
Hub);
b) Recording the clinical data directly onto electronic records through the
Clinic Management System installed for electronic submission of clinical
data for CDMP/CHAS enrolled patients.

3 Deadlines for Submission of Clinical Data to MOH

3.1 Submission of clinical data is an essential component of the CDMP/CHAS.

3.2 We encourage clinics to submit clinical data as soon as possible, during or

immediately after the patient’s clinic visit. Doing this would reduce the backlogs
in submitting clinical data.

58 Chronic Disease Management Programme

3.3 Clinics are allowed to accumulate patient records for submission in batches.
However, for batch submissions, regular (e.g. weekly or monthly) submissions
are encouraged.

3.4 When using the electronic Clinic Management System to capture data during
the consultation, the system may allow submission of data automatically at the
end of each patient consultation.

3.5 The deadline for the clinical data submission will be fourteen days after the end
of each quarter. As an example, for the quarter from Jan to Mar 2017, the
deadline for data submission will be 14 Apr 2017.

Handbook for Healthcare Professionals 59

 Annex B

Data Fields Required for Clinical Data Submission

Patient Details
Patient Name
NRIC/FIN
DOB (dd/mm/yyyy)
Gender Male ( ), Female ( )
Race Chinese ( ), Malay ( ), Indian ( ), Others ( )
Height (m)
Current Smoker Yes ( ), No ( )
Year Started Smoking (yyyy)

Medical History Yes (√) Year of Diagnosis (yyyy)

Hypertension
Hyperlipidemia
Ischaemic Heart Disease (IHD)
Diabetes (DM)
Pre-diabetes
DM Retinopathy
DM Nephropathy
DM Foot Complications
Asthma
Chronic Obstructive Pulmonary Disease
(COPD)
Chronic Kidney Disease (Nephritis/Nephrosis)

Diabetes Treatment Yes (√) Year of Diagnosis (yyyy)

Oral Medications
Insulin
Hypertension Treatment Yes (√) Year of Diagnosis (yyyy)
Oral Medications
Hyperlipidemia Treatment Yes (√) Year of Diagnosis (yyyy)
Oral Medications
Asthma Treatment Yes (√) Year of Diagnosis (yyyy)
Requires Controller

Chronic Disease Management Programme 60

A) Diabetes, Hypertension and Lipid Disorders DMP
For Diabetes, Pre-diabetes, Hypertension and Lipid For Diabetes,
Disorders Hypertension
and Lipid
Disorders
Date of Visit LDL-C Systolic BP Diastolic Weight Avg no. cigs/day
(dd/mm/yy) (mg/dL)/(mmol/L) (mmHg) BP (mmHg) (kg)

For Diabetes only

Date of Visit Glucose HbA1c (%) Eye (√) Foot (√) Nephropathy
(dd/mm/yy) (√)

For Pre-diabetes only

Date of Visit FPG (mmol/L) OGTT (mmol/L) Nephropathy (√)
(dd/mm/yy)

For DM Nephropathy only

Date of Visit Serum Creatinine eGFR Urine ACR
(dd/mm/yy) (μmol/L) (ml/min/1.73m2) (mg/mmol)

B) Asthma and Chronic Obstructive Pulmonary Disease (COPD) DMP

For Asthma, For Asthma For COPD only
COPD only
Date of Visit Avg no. Asthma Weight (kg) COPD Influenza
(dd/mm/yy) cigs/day Control Test Assessment Vaccination
(ACT) Score Test (CAT) (√)
Score

C) Chronic Kidney Disease (Nephritis/Nephrosis) DMP

For Chronic Kidney Disease (Nephritis/Nephrosis)
Date of Visit Systolic BP Diastolic BP Serum eGFR Urine ACR
2
(dd/mm/yy) (mmHg) (mmHg) Creatinine (ml/min/1.73m ) or Urine PCR
(μmol/L) (mg/mmol)

Handbook for Healthcare Professionals 61

CHAPTER FIVE:
USER MANUAL FOR CLINICAL DATA SUBMISSION VIA CIDC E-SERVICE

1 Introduction

1.1 Purpose

1.1.1 The manual serves as a guide on how to use the Clinical Indicators Data Collection
(CIDC) e-Service for the submission of data to MOH as part of CDMP.

1.1.2 The manual is intended for the hospital/clinic staff who are doing clinical data and
indicators submission. The staff should already be familiar with web browsing and the
MediClaim e-Service.

1.2 System Requirements

1.2.1 In order to use the CIDC e-Service, an Internet-enabled computer with the following
is required:

a) Hardware Requirements
The minimum recommended hardware configuration is:
 Pentium III MHz Processor with 256MB RAM
 At least 200 MB free hard disk space

b) System Software Requirements

 Windows XP
 Internet Explorer 6.0 and above
 Broadband Internet Connection

c) Other Requirements
 RSA token card
 MediClaim user account

2 Getting Started

2.1 User Account

2.1.1 You will be using your MediClaim system user account to access the CIDC e-Service.
The MediClaim account is the same one used for the submission of claims.

2.1.2 If you do not have an account for the claims submission, you will need to approach
MOH for the creation of a new account.

Chronic Disease Management Programme 62

2.2 Accessing the CIDC e-Service

2.2.1 The web URL to access the MediClaim system is: https://access.medinet.gov.sg. Refer
to the MediClaim user manual for details on login procedures.

Screen 1: MediClaim Login Screen

2.2.2 Upon successful login to the MediClaim system, you will be able to see the CIDC e-
Service in the left hand menu as shown on Screen 2 below. All users with access to the Chronic
Disease Claim Form e-Service will have access to the CIDC e-Service.

2.2.3 Click on the menu to display the functions available:

Screen 2: Menu

a) Submission is used to submit a new report.

b) Search is used to retrieve submitted reports.

3 Clinical Indicators Report Submission

3.1 This function is used to submit clinical data on patients who have used their MediSave
under the CDMP. A new submission can be made each time there is additional indicator
information for the patient either on a per visit basis or consolidated over a few visits. All
submissions are distinct and will be used for analysis by MOH on a cumulative basis.

3.2 To submit a new set of clinical data for a patient to MOH, click on the “Submission”
sub-menu. The following screen will appear.

Handbook for Healthcare Professionals 63

 Compulsory fields
marked with asterisk * Select patient ID Type

Enter patient NRIC/FIN

Select the medical conditions

applicable to the patient, more than
Click to go to Clinical one medical condition may be
Indicator Form in Screen 4 chosen.

Screen 3: New Submission

3.2.1 Select the Identification Type and enter the Patient NRIC/FIN.

3.2.2 Select the chronic condition applicable to this patient. You can select one or more
conditions, as applicable.

3.2.3 Click on [Next] to proceed to the Clinical Indicator Form.

64 Chronic Disease Management Programme

Handbook for Healthcare Professionals 65
 Screen 4: Clinical Indicator Form

3.3 The Clinical Indicator Form consists of 4 sections:

a) Patient Details,
b) Known Medical History,
c) Clinical and Assessment Indicators, and
d) Attending Physician Information.

4 Patient Details

4.1 This section details the patient’s basic bio-data. If it is your first submission for the
patient, only Patient NRIC, Name, Date of Birth, Sex, Race, and Current Smoker is required.
For subsequent submissions, only the Patient NRIC and Name are mandatory.

66 Chronic Disease Management Programme

4.2 In the event of differences between two submissions, the data from the latest
submission will be considered as the up-to-date information.

Screen 5: Patient Details

5 Known Medical History

5.1 This section details the patient’s medical history. If it is your first submission for the
patient, please enter all the details. For subsequent submissions, you can omit the details if
there are no changes.

5.2 If you are unsure whether you have submitted the information, it is recommended
you fill in the details.

If selected, the corresponding Textbox is disabled unless

date must be filled up as well corresponding checkbox is checked

Screen 6: Known Medical History and Treatment Sections

Handbook for Healthcare Professionals 67

 5.3 Enter the relevant medical conditions for the patient. If a particular condition is
selected, then the year of diagnosis is mandatory. You only need to fill in medical conditions
that apply to the patient.

6 Clinical Indicators and Assessment

6.1 This section enables you to enter the indicator measurement and assessment done on
the patient over any period. Only measurements and assessments not reported previously
need to be entered in this section.

6.2 Initially there will be no clinical indicators added to the report.

6.3 Fill in all the clinical indicators and use the [Add Indicators] button to save them (as
shown in Screen 7).

6.4 There must not be any unsaved data left in the Clinical Indicators Section before
submitting the form.

Add all Clinical

Indicators into the
table below after filling
in the form above

68 Chronic Disease Management Programme

 Screen 7: Filling in the Clinical Indicators

Click to sort the records

Delete after selecting the checkboxes All entries saved in the table will
of the unwanted Clinical Indicators be submitted to the CIDC system

Screen 8: Clinical and Assessment Indicators

6.5 After saving the data, you can use the delete button to remove any mistakes.

6.6 By default, the data displayed is sorted by date of visit and indicators. You can also
click on the “Indicators” and “Date” headers to sort the data according to your preference.

6.7 After saving the data, you can use the delete button to remove any mistakes.

6.8 By default, the data displayed is sorted by date of visit and indicators. You can also
click on the “Indicators” and “Date” headers to sort the data according to your preference.

7 Attending Physician Information

7.1 This section details the physician attending to the patient. It is required for each
submission.

Handbook for Healthcare Professionals 69

 7.2 If there is more than one physician attending to the patient, the main physician
information should be entered here.

Screen 9: Physician Information

8 Report Submission

8.1 Once you have completed the data entry, you can submit the report to MOH by
clicking on the [Submit] button.

8.2 If you are not yet ready to submit, you can click on the [Save Draft] button and retrieve
the report later from the search function for submission.

The Table below describes the function for each button:

Button Function Description

Submit Submits the form after completion.
Deletes any existing drafts saved previously.
Save Draft Saves the inputs in the unfinished form as a draft for
completion in the future.
Close Closes the current form and returns to the main
menu.

9 Search Clinical Indicator Reports

9.1 After you have submitted a report or created a draft, you can retrieve the reports at a
later stage using the search function. This function allows you to specify search criteria and
retrieve all reports matching the criteria.

9.2 After retrieving the report, you can also proceed to “Amend” it if there was any
mistake in the previous submission, or delete it altogether.

9.3 To access this function, click on the “Search” sub-menu under the “Clinical Indicators”
main menu as shown on Screen 10.

70 Chronic Disease Management Programme

 Screen 10: Search Menu

9.4 The Search page will be shown. Enter your search criteria and click on the [Search]
button. The search is case insensitive.

9.5 At least one of the search criteria must be entered before you can proceed with the
search.

Fill in at least one

search criteria
before doing a
search

Screen 11: Search Criteria

9.6 All submissions made by your clinic which matches the criteria will be displayed as
shown on Screen 12.

Handbook for Healthcare Professionals 71

 Click to retrieve all records that match
the specified criteria

Check only one record for

amendment or many records
for deletion

Click on the hyperlink to

retrieve a read-only page
of the record

Amend Delete selected

selected record records

Screen 12: Search Results

9.7 If the number of search results is too large, you can either specify more restrictive
search criteria or use the page number to navigate through the results.

9.8 Click on the Patient Name hyperlink to view the report submitted.

9.9 When the [Amend] button is clicked, the selected record will be displayed in editable
mode as shown on Screen 13.

72 Chronic Disease Management Programme

Handbook for Healthcare Professionals 73
 Screen 13: Editable Page of Patient Record

10 CIDC Clinic Reports

10.1 This function provides standard report(s) for use by clinics. One report is currently
available and additional reports may be added in future releases.

10.2 To access this function, click on the CIDC Clinic Reports under the Reports menu
button. A page displaying all the available reports and their description will be loaded.

Click on Reports menu and select CIDC

Clinics Reports

Screen 14: CIDC Clinic Reports

74 Chronic Disease Management Programme

10.3 List of NRICs for patients for whom Clinical Indicators have not been submitted:

a) This report enables the clinics to have a listing of all the patients’ NRICs for
whom the clinics had made claims in the specified year but no clinical indicator
reports were submitted within a fixed period of 12 months from the claim
submission date of each patient. This report is built in to assist doctors and
clinics to keep track of the outstanding clinical indicator reports they would
require to submit with each claim.

b) Click on the report title from the list of available reports as shown on Screen
15. A report page with a textbox would appear for the user to key in the year
of the requested report, as shown below.

Click on a Report title from the list

of available reports

Screen 15: Selecting a Report

c) Upon entering a valid year, a list of patient NRIC numbers will be generated. The report
generated below shows the record of a patient who had a claim submitted but with
no submission of any clinical indicator.

Screen 16: Viewing a Report

11 Troubleshooting

11.1 Enabling of Pop Ups: Certain screens within the application will be displayed as pop-
up windows. In order to access the full system functionality, you need to enable pop-up
windows for the MediClaim website. To enable this feature, follow the steps below:

Handbook for Healthcare Professionals 75

 a) Select Tools>Pop-up Blocker> Pop-up Blocker Settings…

Screen 17: Internet Explorer Menu

b) Enter “*.medinet.gov.sg” and “*.moh.gov.sg”, then click on Add.

Screen 18: Configuring Pop-up Blocker

76 Chronic Disease Management Programme

12 Fall-Back Procedures

12.1 In the event that the submission cannot be done online immediately, you can keep a
record of the information and submit it at a later date.

13 Contact Information for Queries Related to Clinical Data Collection and Submission

13.1 For online e-service related technical queries, please e-mail to

mediclaim@ncs.com.sg, or contact NCS at: 6776 9330 (Mon - Fri, excluding public holidays,
8:30 am to 6:00 pm).

13.2 For clinical data collection and submission issues related feedback, please email to
moh_cds@moh.gov.sg (preferred method), or contact at: 6325 1757 (Mon - Fri, excluding
public holidays, 8:30 am to 6:00 pm).

Handbook for Healthcare Professionals 77

CHAPTER SIX:
FREQUENTLY ASKED QUESTIONS

A. CLINICAL MATTERS
For Doctors who have already registered in the CDMP/participating in CHAS

Q1. I have a patient with Diabetes Mellitus, Hyperlipidaemia and Asthma. Which DMPs
should I enrol him/her into?

Your patient should be enrolled into both Diabetes AND Asthma DMPs. He/She will then
be able to use MediSave/CHAS to co-pay for the total bill for the treatment administered
for all 3 conditions. However, you will also need to submit clinical outcome data based
on the essential care components of Diabetes, Lipid Disorders and Asthma. (Please refer
to Annex A on page 10 for details.)

Q2. My patient has DM, however, he also has symptoms and signs of Hypothyroidism. Can
I use his MediSave/CHAS to co-pay the thyroid function test?

In this instance, thyroid function test was done to screen for a possible condition and
not for monitoring of the primary condition or its complication(s). Hence, it is suggested
that his bill be itemised so that the patient can use cash to pay for the thyroid function
test and MediSave/CHAS to co-pay the rest of the bill which is related to DM care
components. (Please refer to Chapter 2.)

Q3. Who decides on the stipulated clinical care components?

The clinical care components were drawn from the MOH Clinical Practice Guidelines,
with inputs from professional bodies, which include leading specialists in the respective
fields and respected primary care physicians. They were also endorsed by the Clinical
Advisory Committee.

Q4. What if the patient has symptoms suggestive of both Asthma and COPD? Which DMP
should I enrol him into?

For patients whose signs and symptoms are not so distinct between the two conditions,
spirometry and/or bronchodilator reversibility testing may be performed to help classify
the patient into one of the two diagnoses or to differentiate these conditions from other
diseases that may mimic its presentation.

It is important to try to classify the patient into the correct DMP as this will help to
determine the management of the patient and also prevent any issues with respect to
the MediSave/CHAS claims.

(Please refer to the MOH Clinical Practice Guidelines for more information on diagnosis
and management of Asthma and COPD).

Chronic Disease Management Programme 78

Q5. Can the patient use MediSave/CHAS to pay for pulmonary rehabilitation?

Yes, only if the patient has been diagnosed to have COPD, and it is clinically deemed to
be beneficial for the patient.

Q6. Can I make claims for ambulatory aids (e.g. walking sticks) for my patient with Stroke,
or for oxygen concentrators for my patient with COPD requiring long-term oxygen
therapy?

Currently, medical devices not used for the purposes of drug administration are
generally not claimable items under MediSave for CDMP/CHAS. However, for a patient
with COPD, he may claim up to $75 per month for rental of devices for long-term oxygen
therapy.

The Seniors’ Mobility and Enabling Fund (SMF) may be used to subsidise purchases of
mobility devices for means-tested patients above the age of 60 years old.

Q7. Can I make claims for Glucosamine/Chondroitin supplements for my patient who has
Osteoarthritis?

You may prescribe Glucosamine/Chondroitin supplements for suitable patients, but

they are currently not claimable items under CDMP/CHAS.

Although Glucosamine and Chondroitin supplements are commonly prescribed for

patients with Osteoarthritis, their benefits have not been supported by sufficient clinical
evidence. Patients’ MediSave/CHAS should only be claimed for evidence-based
medications and treatment modalities, such as physiotherapy.

Q8. Can I claim for outpatient vaccinations and/or health screenings?

MediSave claims for the following are allowed, but not under the CDMP framework.
However, these claims fall under the same withdrawal limit as CDMP, i.e. $500 per
Medisave account per year.

Vaccinations
Vaccinations for recommended groups under the National Childhood Immunisation
Schedule (NCIS) and National Adult Immunisation Schedule (NAIS)

Health Screenings
a) Mammogram screening for women aged 50 and above; and
b) Selected screening tests for newborns in the outpatient setting.

CHAS claims can be made in the following circumstances:

Vaccinations
a) The cost of consultation for vaccinations, but not the cost of the vaccines, can
be claimed under the acute tier of CHAS subsidies; and

Handbook for Healthcare Professionals 79

 b) For patients with COPD, the cost of consultation and influenza vaccine can
claimed under the chronic tier of CHAS subsidies, as it is an essential care
component of COPD.

Health Screenings
Tests for recommended health screening by the Health Promotion Board (HPB) are free
at participating CHAS clinics (doctor’s consultation charges apply). HA/PG/PA
cardholders are eligible for CHAS subsidies for doctor’s consultation charges for health
screening.

B. REGISTRATION MATTERS
For Doctors and Clinics which wish to be registered into the CDMP:

Q1. What are the requirements to be on the CDMP?

Clinics that wish to participate in the CDMP must agree to:

c) Provide treatment to chronic disease patients through evidence-based DMPs.

These DMPs will include MOH-recommended key treatment components;
d) Treat patient medical information with confidentiality;
e) Submit to MOH, with the informed consent of patient, data on patient care
delivery on an annual basis or as specified by MOH, for the purpose of medical
audits. Relevant aggregated performance data will be published to assist
patients in making informed choices;
f) Be accredited for the use of MediSave for CDMP; and
g) Be periodically reviewed and audited, both clinically and administratively. Any
clinic/medical institution that fails to satisfy the minimum standards of clinical
performance set by MOH, will be asked to withdraw from the Programme. (See
Chapter Two: The Clinical Guidelines).

Q2. How do I register for the CDMP?

For clinics who are not in the CDMP, they must submit the following forms for
registration:

a) E-Application for Clinics to Participate in the MediSave for Chronic Disease

Management Programme (by MOH);
b) Direct Authorisation Credit Form (by CPF Board);
c) GIRO Form (MediClaim charges by NCS); and
d) GIRO Form (MediSave charges by CPF Board).

The E-Application website can be accessed via

https://www.mediclaim.moh.gov.sg/mmae/OverviewApplication.aspx

Clinics participating in the CDMP will also have to sign a Deed of Indemnity with the CPF
Board.

80 Chronic Disease Management Programme

 Doctors need to be individually registered under the Programme in order to process
MediSave claims for their patients. Doctors can do so by submitting the Application
Form for Medical Professionals, which can be found in the link:
http://www.mediclaim.moh.gov.sg/mmae/DoctorApplication.aspx.

Q3. My clinic is already participating in CDMP. Can I make MediSave claims for my patient
who is suffering from Schizophrenia, Major Depression, Bipolar Disorder or Anxiety?

In addition to participating in CDMP, your clinic will also need to be participating in a

Shared Care or GP Partnership Programme with a Restructured Hospital before your
clinic is registered as a “CDMP-MI” clinic, and MediSave claims for patients with mental
illnesses can be made. This is part of an assurance framework to ensure quality of care
for patients.

Q4. How do I register for a Shared Care or Partnership Programme with a Restructured
Hospital?

You may register via MOH’s MMAE website

(http://www.mediclaim.moh.gov.sg/mmae/overview.aspx) by selecting the “Chronic
Disease Management Programme (CDMP) – Shared Care Programmes”.

Q5. What will be the cost of registration and start-up?

Apart from computer hardware and Internet access subscription (which may already be
in place), there is a one-time non-refundable cost of $191.20 (inclusive of 7% GST and
delivery fee) for the security token to access the MediSave claims system. The token is
valid for two to three years. The subsequent token is priced at $171.20. This security
token is required only when using the MediClaim e-service.

You or your staff will need to attend a half-day training session on MediSave claims
process, guidelines on MediSave use and the use of the MediClaim system. This training
session is free-of-charge.

Q6. How do patients sign up for the CDMP?

All patients treated by a MediSave and CDMP accredited doctor for at least one of the
approved chronic conditions are eligible for CDMP. The patient need to complete the
MediSave Authorisation Form / Medical Claims Authorisation Form to allow the doctor
to make MediSave claims on the patient’s behalf.

C. MEDISAVE CLAIMS, REIMBURSEMENT, BILLING

For Doctors and Clinics that wish to be registered into the CDMP:

Q1. In total, how much can patients claim from MediSave for chronic disease treatments?

Handbook for Healthcare Professionals 81

 Patients can claim up to $500 per MediSave account per year for outpatient treatment
of the approved chronic conditions, regardless of the number of chronic conditions they
might have.

Q2. Whose MediSave account(s) can a patient make use of, apart from his/her own?

Patients can use their own MediSave account(s) and the account(s) of their immediate
family members (i.e. parents, children, and spouse). In addition, patients who are
Singapore Citizens or PRs can also use the MediSave accounts of their grandchildren.
Claims can be made once the MediSave payer has signed the relevant MediSave
Authorisation Form.

Q3. What will be the exact level of deductible and co-payment?

The $30 deductible has been removed since 1 July 2014. There is still a 15% co-payment
of the CDMP bill for each claim that the patient has to pay in cash.

Q4. Who should submit MediSave claims?

Any of the permanent staff of a MediSave-accredited clinic/medical institution who has

attended the training sessions, e.g. doctors, nurses, counter staff, clinic managers, can
submit MediSave claims.

Q5. If the patient sees me for both a chronic condition and an acute condition at the same
time, can the entire bill be claimed?

MediSave can only be used for treatment related to the CDMP conditions listed, subject
to a cap of $500 per MediSave account per year. If patient attendance is purely for an
acute or unrelated condition, MediSave deduction is not allowed even though the
patient may have an existing chronic condition. Checks will be made during audits to
ensure that claims made are only in relation to the approved chronic conditions and/or
their complication(s).

Q6. How does the annual cycle of the $500 limit apply? Is it calculated based on the time
that the patient first seeks treatment under the scheme?

The $500 annual limit is reset at the start of each calendar year, i.e. $500 for the period
from 1 Jan to 31 Dec.

Q7. Will MediSave use be allowed for purchasing equipment (e.g. blood pressure
monitoring equipment or glucometer, etc.)?

In line with existing MediSave guidelines, MediSave use generally does not cover
equipment purchase, whether for chronic disease treatment or other uses. From 1 Jun
2015, MediSave can be used for the purchase of spacers and accompanying masks if
necessary, for Asthma/COPD patients, as well as insulin pens, syringes and needles for
Diabetic patients. From 1 Jun 2018, MediSave can be used for the purchase of lancets
and glucose test strips for self-monitoring of blood glucose levels for Type 1 Diabetes

82 Chronic Disease Management Programme

 patients and Type 2 Diabetes patients on insulin. These should be dispensed in
appropriate quantities, necessary for the patient’s own use.

Q8. How will I know if the patient has sufficient balance left for claims?

To help patients and their family members keep track of the amount of MediSave used
under MediSave500, participating clinics can check the MediSave balances under the
CDMP on behalf of their patients, upon authorisation from patient.

An enquiry function to check the available withdrawal amount is available via the
MediClaim e-service and MHCP. Clinics may use this function to check the remaining
balance of the MediSave account holder with his/her consent.

Alternatively, you can request for the MediSave holders to show you a print-out or
electronic statement of their current MediSave balance. They can obtain their current
MediSave balance from the CPF Board's website (www.cpf.gov.sg) under My CPF Online
Services - My Statement, by logging in with their SingPass. You may wish to ask your
patients to bring along a copy of the MediSave balance of the Medisave payers if you do
not have a computer terminal at your clinic.

Q9. If the MediSave balance is insufficient to cover the costs, can the patient top up the
difference in cash?

Yes.

Q10. Can the bill be split among two or more accounts according to a given percentage?

Yes, a claim can be shared by a maximum of 10 MediSave accounts.

Q11. Will patients have to pay the full amount upfront and then be reimbursed or can they
make partial payment based on estimated MediSave payout?

This decision will depend on the individual clinics. However, clinics should explain to
their patients on the mode of payment clearly so as to avoid any confusion or
unhappiness.

Q12. How will refunds for MediSave withdrawals be handled (e.g. if a patient opts out of a
package)?

The clinic will have to amend the approved MediSave claim through the MediClaim
system to return the money back to the relevant MediSave accounts. CPF Board will
liaise with the clinics to debit and credit the amounts accordingly. MediSave will have
first claim on any refunds. Clinics should refund the patient the unutilised cash co-
payment collected from the patient previously.

Q13. If patients have signed up for the Programme, can they opt out of it at a later date?
Do I need to refund the amount that he had paid up for a package?

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 Patients can opt out at a later date by informing the clinic from which he/she is receiving
care. Funds withdrawn from MediSave must be reimbursed to the MediSave accounts.
Refunds on cash co-payment is a private arrangement between the provider and the
patient. Patients should find out the provider’s policy on refunds before signing up for
packages.

Q14. Is MediSave withdrawal dependent on the patient having only one specific primary
care provider?

No. Patients are encouraged to have continuity of care with one family physician but
they are free to choose and switch providers. Hence, they can make MediSave claims at
any MediSave-accredited clinic.

Q15. How will claims be made if a patient is referred to an unaccredited provider?

MediSave claims will not be allowed at an unaccredited clinic. However, the referring
party can make arrangements to bill on behalf of his unaccredited partners. The
referring party is expected to bear full responsibility for any such arrangements made.
In addition, the referring party is also responsible for the submission of clinical data for
the patient.

Q16. How will the scheme apply to Permanent Residents and Foreigners?

Current MediSave rules apply. As long as Permanent Residents or Foreigners have

MediSave accounts or their immediate family members have MediSave accounts, they
are eligible for the scheme.

Q17. How will the scheme apply to those who have employer medical benefits or an
existing comprehensive insurance plan?

Claims can be made under employer plans. This also applies to pensioners. Employer
medical benefits or an existing comprehensive insurance plan can be used to cover the
cost of the deductible and co-payment. Any amount in excess of the employer medical
benefits or the insurance plan can be paid using MediSave, subject to co-payment.
Clinics will have to liaise directly with their partnering employers for payment under
employer plans as per their current arrangements.

Q18. What is the process of making MediSave claims like? Will it involve a huge change in
my clinic operations?

The process is as follows:

a) The clinic/doctor should explain the following to patients suffering from any of the
approved chronic conditions and their immediate family member(s) whose
MediSave account(s) is/are being used (if any):
 the treatment components
 the cost of treatment
 estimated amount that can be claimed from MediSave

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  the out-of-pocket cash payment that the patient will need to make

b) When the patient and/or his/her immediate family member(s) have decided to use
MediSave for the bill, each MediSave account holder who wishes to make use of
his/her MediSave account need to sign a MediSave Authorisation Form / Medical
Claims Authorisation Form to authorise the CPF Board to deduct his/her MediSave
savings for the treatment of the patient. The authorisation can be made on a per
treatment basis or over a period. Authorisations over a period of time stands until
revoked in writing. Clinic/medical institution staff should witness the signing and
verify the relationship(s) to the patient as stated in the MAF.

c) Clinics/medical institutions can then submit the MediSave claims electronically to

the CPF Board for processing via the MediClaim System.

d) Payment will be made daily to MediSave-accredited medical institutions via

InterBank Giro (IBG) on the 3rd working day after the approval date of the MediSave
claims.

Q19. Can GPs who are contracted by nursing homes to provide outpatient care for their
residents help the ones suffering from one of the approved chronic conditions make
MediSave claims?

Yes, if the GP and his/her clinic are accredited for MediSave use for CDMP. He/She can
help the nursing home patients to make a MediSave claim for their outpatient chronic
disease treatment(s) through his/her clinic.

D. DATA SUBMISSION, CLINICAL IMPROVEMENT AND AUDITS

Q1. Why is the patient’s medical and treatment history required?

The data collected will provide a better profile of patients on CDMP/CHAS. This
information will be useful for fine-tuning for programme planning and management
purposes.

Q2. Must the medical history be captured at each visit?

The items in the medical history data will only need to be captured once but should be
updated as and when there are changes.

Q3. How do I record the actual year of diagnosis of patients with long standing chronic
diseases?

The estimated year of diagnosis for the patient’s chronic condition can be recorded if
the exact year is not known.

Q4. Will data on all clinical parameters be required at every visit?

Handbook for Healthcare Professionals 85

 No. Only data on assessments or tests performed during the visit need to be captured.

Q5. Would I need to repeat HbA1c or LDL cholesterol if my patient is able to produce the
results of a test done elsewhere?

You can submit the relevant details of your patient’s test results that have been
performed elsewhere instead of repeating the test. If you do so, please keep a copy of
the record of the test results.

Q6. What if the patient is lost to follow up?

Please note it down in your clinical documentation. Alternatively, if you are using the
web-based CIDC e-Service for data submission, you may also document the information
using the textbox available under the Patient Participation Module present on the
navigation bar. If you are using CMS for data submission, please contact your CMS
provider for more details on capturing of this type of information electronically.

Q7. What if the patient refuses certain tests?

Tests are performed, when indicated, as part of the proper management of the chronic
disease. As such, the physician should inform the patient as to the rationale and provide
other key information regarding these tests. If the patient refuses the tests, please note
this response in the patient’s clinic notes.

Q8. If I missed the previous deadline for submission of clinical data, do I still need to
submit the data for that period?

Yes, you should still submit the relevant data for that period as well as the current data.

Q9. Which healthcare provider should submit clinical data if the patient makes
MediSave/CHAS claims at three different healthcare providers during one year?

It would be appropriate for each provider to collect relevant data for the care that has
been provided, and to submit the data. If they are not able to make the submission,
they should forward the data to the primary physician who is coordinating the care of
the patient’s chronic condition so that he/she may be updated and make the submission.

Q10. If a patient starts making MediSave/CHAS claims from June onwards, must I submit
clinical information captured before June?

You can capture the relevant clinical data of the patient. However, for the purpose of
assessing the care process and outcome of the chronic condition, the period of one year
(taken from the date when the patient first enrolled into the CDMP/CHAS for the chronic
condition) will be used.

Q11. My patient claimed MediSave/CHAS for treatment of a chronic condition when he first
consulted me on 5 Jan 2014, but paid cash for three subsequent visits (in Mar, Jul, Oct

86 Chronic Disease Management Programme

 2014) for the same chronic condition. Would I still need to submit clinical data for the
latter three visits?

Yes, you should continue to submit the patient's clinical data on this chronic condition
for one year from 5 Jan 2014.

Q12. Can the clinical data submitted be shared by different healthcare providers within the
same clinic / institution / cluster?

This will depend on the electronic Clinic Management System (if any) that is used by the
healthcare institution.

Q13. If I have already fulfilled the number of care components for the chronic condition, do
I still need to submit clinical data subsequently?

The care components are the essential aspects of medical care that are recommended
for management of the chronic conditions. The data submission system allows you to
submit more than the recommended number of care components.

Q14. Will clinical data submitted be shared with the providers?

The clinical data received will be used to monitor the success of the CDMP/CHAS, and
also to give feedback routinely to the registered clinics for quality improvement. Clinical
data submitted have been routinely fed back to the clinic as the online CDMP outcome
reports via the Mediclaim system from the first quarter 2008 onwards. In these reports,
a clinic will be able to compare its performance against the aggregated local and national
performance. Over time, each clinic will also be able to track its own performance trends.

Q15. What will the clinical quality improvement process be like?

The clinical data that is monitored is useful for clinical quality improvement in the care
of chronic conditions. When meaningfully used, it will empower patients to take charge
of managing their chronic condition as guided and supervised by their family physician.
This can improve compliance with the recommended care of the chronic condition(s)
with better longer term outcomes.

Q16. What will the clinical audit process be like?

Periodic audits will be carried out to ensure accuracy of clinical data submission and to
ensure that minimum standards of performance are met. Due consideration will be
given so that such audits do not disrupt clinic operations and patient care processes.

Q17. What documents must I submit if my clinic is selected for audit?

Photocopies of the following documents should be submitted by post:

a) Doctor’s clinical notes for the visit/visits submitted for specified claim;

Handbook for Healthcare Professionals 87

 b) Laboratory results relevant to the medical condition(s) for which claim was made
e.g. HbA1c, Lipid Panel, Spirometry test etc;
c) Prescription or clinical notes with documentation of details of the drugs prescribed
(i.e. name of drug, frequency, dose, duration); and
d) Invoices/receipts showing the itemized breakdown (medication(s), investigation
(if any), consultation & total claim amount) of the bill(s) submitted for claim.

Q18. Am I allowed to divulge patients’ medical information to the CDMP/CHAS Audit Teams
for audit?

Yes, clinics are subject to audits by CDMP/CHAS Auditors appointed by MOH, as stated
in the Agreements. In addition, the patient would have provided consent to sharing
his/her medical information for the purpose of the audit when he/she signed the
MediSave Authorisation Form/Medical Claims Authorisation Form/CHAS Patient
Consent Form.

Q19. How do I submit my bills for audit?

All items claimed need to be itemised.

88 Chronic Disease Management Programme