HEALTHCARE BENEFIT ORIENTATION ZIGZAG MEDIA INC. Period of Coverage November 14, 2016 to November 13, 2017

Transcription

1 HEALTHCARE BENEFIT ORIENTATION ZIGZAG MEDIA INC. Period of Coverage November 14, 2016 to November 13, 2017

2 CORPORATE PROFILE Established in ,000,000 Members Nationwide Extensive Network Accreditation Approximately 1,300 hospitals, clinics & diagnostic centers Over 18,000 reputable physicians and specialists More than 880 dentists Strong Manpower Complement and Infrastructure 24/7 Customer Service Assistance Patient Relations Officers Over 1,500 Strong Workforce 4 Regional Offices (Cebu, Bacolod, Davao, Calamba) 14 Satellite Offices (CDO, Angeles, Legaspi, Dumaguete, Iloilo, Zamboanga, General Santos, Kidapawan, Roxas, Ormoc, Tacloban, Tagbilaran, Tagum, Bukidnon) Beyond 90% Client Retention Rate

3 DIVERSE CLIENTELE

4 DIVERSE CLIENTELE

5 ELIGIBLE MEMBERS 1. PRINCIPALS Permanent Employees up to age 65 years old 2. DEPENDENTS Eligible dependents of permanent employees, provided hierarchy is followed

6 ELIGIBLE DEPENDENTS HIERARCHY RULE: For Single Principal Members 1. Mother or Father not over 65 years old 2. Siblings (Eldest to Youngest) 30 days - 21 years old Unmarried Unemployed

7 ELIGIBLE DEPENDENTS HIERARCHY RULE: For Single Parent Principal Members 1. Children (Eldest to Youngest) Biological / Legitimate / Legally adopted 30 days 21 years old Unmarried Unemployed 2. Mother or Father not over 65 years old 3. Siblings (Eldest to Youngest) 30 days - 21 years old Unmarried Unemployed

8 ELIGIBLE DEPENDENTS HIERARCHY RULE: For Married Principal Members 1. Legal spouse not over 65 years old 2. Children (Eldest to Youngest) Biological / Legitimate / Legally adopted 30 days 21 years old Unmarried Unemployed

9 ENROLMENT GUIDELINES Enrollment period 30 days window Dependents 30 days from effective date of coverage No additional dependents except for: Newly born baby 30 days from date of birth Spouse of newly wed employees 30 days from date of marriage Dependent of a new employee 30 days from effective date of Principal member

10 BENEFITS ROOM & BOARD AND MBL PRE EXISTING CONDITIONS PREVENTIVE CARE OUT PATIENT CARE IN PATIENT CARE EMERGENCY CARE DENTAL CARE

11 ROOM & BOARD/ MAXIMUM BENEFIT LIMIT Room and Board Maximum Benefit Limit / MBL (Regardless of the price) (Per type of illness) SEMI PRIVATE 100,000 SMALL PRIVATE 100,000 REGULAR PRIVATE 150,000 PhilHealth Required

12 MAXIMUM BENEFIT LIMIT Dependents Enrolled after Six Months from effective date of coverage shall be on Pro-rated basis.

13 PRE-EXISTING CONDITION COVERAGE Existing Principals New Principals MBL MBL Existing New Dependents Dependents Php 5,000 80% RULE NOTE: If the 80% rule is not met, pre-existing conditions or dreaded diseases shall not be covered on the first twelve (12) months of healthcare coverage. What are PRE-EXISTING CONDITIONS? Conditions existing prior to effective date of coverage Professional advice sought for such illness prior to effective date Illness or injury evident to member Nature of disease or illness can be clinically determined to have started prior to coverage whether the member is aware or not The following are examples of PEC: Hypertension, goiter, asthma, TB, gall or kidney stones, diabetes, tumors, myoma, arthritis, scoliosis, hernia, prostate disorders etc.

14 PREVENTIVE CARE ANNUAL PHYSICAL EXAMINATION(APE) Basic 5 Pap smear and ECG for 35 years old and above To be scheduled by your HR / in coordination with Intellicare For ALL Employees Routine Immunization (except cost of vaccines)

15 OUT PATIENT CARE Medical Consultations with Intellicare affiliated doctors Referral to Intellicare accredited specialists Treatment of minor injuries such as lacerations, mild burns, sprains and the like Laboratory, x-ray, and other diagnostic procedures prescribed by an Intellicare accredited physician Minor surgery not requiring confinement Pre- and post-natal consultations with any Intellicare affiliated OB-GYN up to 14 consultations/year. Speech / Physical Therapy up to 12 sessions per year.

16 OUT PATIENT AVAILMENT Letter of Eligibility/LOA IF DECLINED, attending medical staff will all I telli are s Customer Service for assistance. File PhilHealth for required procedures

17 OPTIONS FOR OUT PATIENT

18 OUT PATIENT CARE PARTNERS Aventus Makati Clinic Clinic Hours: Monday-Saturday / 8am to 5pm 6th floor Filomena Bldg., 104 Amorsolo St., Legaspi Village, Makati City Tel # / / / / Aventus Alabang Clinic Clinic Hours: Monday-Saturday / 8am to 6pm 2nd Floor Sycamore ARC 1 Building, Buencamino St., Alabang-Zapote Road, Alabang, Muntinlupa City Tel # / / Aventus Ortigas Clinic*** Clinic Hours: Monday-Saturday / 8am to 5pm Ground Floor, AIC Realty Corporate Center, Sapphire St., Ortigas Center Tel # / / (NOTE: Bring 2 valid IDs for the building and clinic, slippers and shorts are not allowed) Aventus Cebu Clinic Clinic Hours: Monday-Saturday / 8am to 5pm Unit 203 2/F TGU Tower I.T. Park Asiatolon, Apas, Cebu City Tel # (032) / ; Fax # (032)

19 OUT PATIENT CARE PARTNERS Aventus Calamba Clinic Clinic Hours: Monday-Saturday / 8am to 5pm Unit SQA Corporate Center, Barangay 1 National Highway Crossing, Calamba, Laguna Tel # (049) / (049) Aventus Sta. Rosa Clinic Clinic Hours: Monday-Saturday / 7am to 4pm 2nd Floor Carvajal Building 2 National Highway, Balibago, Sta. Rosa, Laguna Tel # (049) Manila Line: Tel # Aventus U.N. Avenue Clinic*** Clinic Hours: Monday-Saturday / 8am to 5pm 5/F Times Plaza Bldg., U.N. Ave. corner Taft Ave., Ermita, Manila Tel # / (NOTE: Bring 2 valid IDs for the building and clinic, slippers and shorts are not allowed) Aventus PCS Clinic Clinic Hours: Monday-Saturday / 7am 5pm 2nd Floor Philippine College of Surgeon Bldg., 992 North Edsa, Quezon City Tel. # to 77

20 IN PATIENT CARE Room & Board Accommodation within the limits of the PLAN Professional fees of attending Intellicare affiliated physicians Diagnostic procedures referred by the attending Intellicare affiliated physicians / specialists. Administered Medicines either orally or intravenously Transfusion of blood and intravenous fluids Anesthesia and its administration

21 IN PATIENT CARE Standard nursing care services, standard admission kit, sutures, dressings, plaster casts, and other items directly related to the medical management of the patient Use of Intensive Care Unit Use of Operating Room & Recovery Room facilities Assistance in administrative requirements through the Intellicare s Patient Relation Officers Ambulance Service (hospital to hospital & point of incident to hospital) to be covered thru reimbursement up to Php 3,000/conduction/member/year

22 IN PATIENT AVAILMENT Secure an admitting order from an Intellicare accredited doctor. Proceed to the admitting section and have your card SWIPED for validation of membership eligibility. If approved, In-patient LOE will be printed. (Sign the LOE). Present the admitting order and LOE. (For emergency cases, confinements will be directly facilitated by the ER staff). IF DECLINED, staff will all I telli are s Custo er Service for assistance. Sign the Referral Control Sheet (RCS) 3 to be issued y I telli are s Patie t Relation Officer (PRO). Settle any miscellaneous/additional charges upon discharge. (Please double check or validate items charged if correct.) Occupy allowed room. File your Philhealth before hospital discharge. Inform Intellicare office regarding admission within 24hours.

23 ACCESS TO IN PATIENT CARE Q: If the room that I am entitled to is fully occupied, could I occupy higher room categories? (Involuntary Room Upgrading) If entitled Room is not available, member may occupy (1)One category higher (except suite room) and pay only for the ROOM AND BOARD DIFFERENCE, Intellicare will cover the incremental charges. If within confinement the entitled room becomes available member should transfer automatically to their allowed room category. Otherwise, pay all incremental charges.

24 ACCESS TO IN PATIENT CARE Q: If I want to stay in a more expensive room, and am willing to pay for the accommodation, may I do so? (Voluntary Room Upgrading) Yes. However, keep in mind that staying in a more expensive room also makes the other services (i.e., medicines, professional fee, etc.) more expensive. You will be charged for the excess over your entitlement and should pay the excess upon discharge (approximately 30% of your total hospital bill, excess room & board and doctor s fee). All excess bills shall be collected from you before discharge.

25 EMERGENCY CARE EMERGENCY CASES are life-threatening situations requiring urgent medical or surgical care e.g. heart attack, stroke, poisoning, loss of consciousness or respiration and convulsion. Accredited Hospitals Non-Accredited Hospitals Foreign Territories for ER Confinement Covered up to MBL Covered thru reimbursement up to Php 30,000 Covered thru reimbursement up to Php 30,000 Hospital Bills 100% Intellicare s RVS Hospital Bills 80% Intellicare s RVS Hospital Bills 80% Intellicare s RVS Professional Fees % Intellicare s RVS Professional Fees 80% Intellicare s RVS Professional Fees 80% Intellicare s RVS *Relative Value Scale (RVS) rates supposedly paid by HMOs to accredited Hospitals

26 REIMBURSEMENT 1. Secure Intellicare reimbursement form from and fill out completely. 2. Complete the following documents and attach to the Reimbursement Form: OUT PATIENT IN PATIENT Original Official Receipt (with TIN) Statement of Account from the Hospital Medical Certificate Laboratory result (if w/ diagnostic procedure) Original Official Receipt (with TIN) Statement of Account from the Hospital Medical Certificate Laboratory result (if w/ diagnostic procedure) Operative record with histopath (if with operation Police report & Medico-legal Report (if required) NOTE: Submit to Intellicare not more than 30 days from expiration of treatment Intellicare will process the request within 20 working days upon receipt of complete documents

27 OTHER BENEFITS Anti-rabies, anti-venom and anti-tetanus vaccines shall be covered up to Php20, each per member per year Cauterization of warts (from neck down except genital warts) shall be covered up to Php1, per member per year to be done at any Aventus Clinics only provided that an accredited physician recommends it and only for cases that affect the physiological functions of the member (not for cosmetic/aesthetic purposes). Sclerotherapy shall be covered up to Php5, per leg per member per year provided that it is medically necessary and recommended by an affiliated vascular surgeon (not for aesthetic purposes). Congenital illnesses/ Conditions shall be covered up to PEC limit not to exceed Php20, per principal member per year Tuberculin Test shall be covered up to Php per member per year if the member shows symptoms of Tuberculosis and if prescribed by accredited physician.

28 OTHER BENEFITS Scoliosis, slipped disc, spondylosis and spinal stenosis shall be covered up to PEC limit per year Allergy Testing shall be covered up to the maximum benefit limit per member per year if prescribed by Accredited Physician except for Allergy Screening which shall be covered up to Php5, per member per year if prescribed by Accredited Physician Work-related illnesses/ injuries shall be covered up to the maximum benefit limit per year subject to the exclusions and limitations of the contract Eye laser treatment for retinal hole, retinal detachment and glaucoma (excluding eye correction such as lasik, PRK and the like) shall be covered up to PEC limit per year Cataract surgery excluding cost of lens shall be covered up to PEC limit per year

29 OTHER BENEFITS Unprovoked murder & assault shall be covered up to the maximum benefit limit per year subject to the exclusions and limitations of the contract and a police report must be submitted to Intellicare for evaluation Vehicular accidents shall be covered up to the maximum benefit limit per year subject to the exclusions and limitations of the contract and a Police report MUST be submitted to Intellicare for evaluation. Chronic dermatoses and scabies shall be covered for consultations only Sports related injuries that are acquired during company sponsored events EXCEPT for hazardous sports shall be covered up to Php10, per member per year subject to the exclusions and limitations of the contract.

30 DENTAL BENEFITS Dental Examination Twice a year oral prophylaxis Simple tooth extraction Temporary fillings Permanent light cure filling - up to two (2) teeth per year Desensitization of Hypersensitive teeth - up to two (2) teeth per year Recementation of jackets, crown, inlays and onlays Treatment of minor gum problems, mouth lesions, wounds, and burns Orthodontic consultations (braces and malposition of teeth) Temporo mandibular joint consultation (clicking of jaws) Pre-natal check of teeth and gums Emergency dental treatment for the relief of pain Dental health education

31 DENTAL AVAILMENT Check list of Intellicare accredited dentists (you may refer to your guidebook or Intellicare website or call Intellicare Customer Service for assistance). Call the dentist to confirm schedule and inquire if by appointment or walk-in patients are accommodated. Proceed to the dental clinic on the day of your dental availment and present Intellicare card for validation. Sign Referral Control Sheet (RCS) 5 available at the dental clinic. Avail entitled dental benefit.

32 FINANCIAL ASSISTANCE (FOR ENROLLED PRINCIPAL MEMBERS ONLY) Natural Death - Php 25, Death due to Accident - Php 50, Loss of both hands - Php 10, Loss of both feet - Php 10, Loss of sight (both eyes) - Php 10, Loss of one hand and one foot - Php 10, Loss of one hand and sight on one eye - Php 10, Loss of one foot and sight on one eye - Php 10, Loss of one hand or one foot or sight on one eye - Php 5,000.00

33 GENERAL EXCLUSIONS AND LIMITATIONS Out-of-Network services Miscellaneous hospital charges Health check ups (Pre-employment,Government reqs,insurance) Special Confinements (sanitarium,home for the aged, etc) Medical Certificates Professional fees in medico-legal cases Refusal to undergo recommended treatment or demanding treatment for which Intellicare doctors believe a professionally acceptable alternative exists Blood screening Vaccines For immunization Animal bites (anti-rabies, anti-venom), Steroid injections Organ transplants or acquisition of an organ Procurement of Orthotics, Prosthetics, take-home appliances and other durable medical equipment (DME) Determining / Ruling out PEC during the first 12 months of membership - if result is positive medical

34 GENERAL EXCLUSIONS AND LIMITATIONS Reproductive disorders, artificial insemination, circumcision, sex change Laser eye surgery for myopia or error of refraction Alternative medical treatment / procedures Sleep study not due to an organic illness Cosmetic alterations for aesthetic purposes Out patient medicines and medical supplies Dental Surgery, Dental X-Ray, Impacted tooth/wisdom tooth Idiopathic diseases and auto-immune disorders Hypersensitivity / Allergy testing; Allergy desensitization Any disability which may have affected a dependent prior to the 30th day after birth Pregnancy and pregnancy-related conditions

35 GENERAL EXCLUSIONS AND LIMITATIONS EXTERNAL FORCES / ACTIVITIES Exposure to imminent danger or health hazards Violation of a law or ordinance Extreme Hazardous Sports-related injuries Fortuitous events/disasters Air or sea travel other than a fare-paying passenger on a licensed aircraft/vessel ILLNESSES / CONDITIONS Congenital Abnormalities Neuro-developmental disorders, genetic disorders which may result to mental retardation, and other conditions which may require speech/physical and other related therapies Developmental delay Sexually-transmitted diseases, AIDS and AIDS-related complex or condition Psychiatric and psychological illnesses

36 MEMBERSHIP CARD Always present your Intellicare Membership Card and another valid ID during availment. Lost / Damaged card report to Intellicare immediately PHP replacement fee for lost card

37 Go-To Intellicare (Android Phones)

38 IntelliMap (Android Phones) IntelliMapPh (ios Phones)

39 Accredited list of Reminder: Please do check the list of affiliated Doctors and Hospitals for this is subject to changes without prior notice.

40 CUSTOMER SERVICE HOTLINE TOLL-FREE NUMBER OUTSIDE METRO MANILA MANILA/ LUZON (For Call) (For Text) (0920) Smart (0917) Globe (0920) Smart (0917) Globe BRANCH OFFICES CALAMBA (049) CEBU (032) (0920) BACOLOD (034) (0920) CDO (0882) (0920) DAVAO (082) (0920) ADDRESS: info@intellicare.net.ph

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