FREQUENTLY ASKED QUESTIONS

Transcription

1 FREQUENTLY ASKED QUESTIONS 1. How do I avail of health care in the absence of my HMO ID? You may call Intellicare s 24/7 Customer Service Numbers for us to provide you your account number and endorse you to the facility where you wish to avail. 2. What if I lose my HMO ID? Kindly coordinate with the on-site clinic and prepare Php processing fee Call Intellicare Customer Service Hotline for endorsement if you will avail our services in the absence of the card. 3. How can I enroll my dependents under the plan? Enroll your dependents through the CVG Intellicare portal ( within 30 days from the date of hire and submit the required supporting documents to the on-site clinic. - or - Secure a copy of the manual enrolment form from your on-site clinic, fill it out and submit the required supporting documents Required documents: To enroll spouse: attach a copy of Marriage Contract To enroll child: attach a copy of Birth Certificate or Certificate of Live Birth To enroll parent: attach copies of your Birth Certificate and your parent s Birth Certificate 4. When should I enroll my dependents? New hires must submit the form and required document/s within 30 days from date of hire Regular employees may enroll dependents: When the enrollment period is opened which happens either by the end of the year or early next year (Once schedule is confirmed, communication will be provided by your HR and/or onsite clinic) For employees who got married: Within thirty (30) days from date of marriage (parents cease to be dependents upon marriage regardless of whether employee enrolls spouse or not) For employees with new born babies: Within forty-four (44) days from the child s date of birth. Any requests for additional dependents beyond these deadlines shall not be allowed for whatever reason (Birth Certificate cannot be found, delayed release of Marriage Contract, employee was on Maternity Leave, etc.) 5. When does coverage for my dependent start? For new hires: On the third or seventh month of employment depending on the employee s job level Intellicare Page 1

2 For new dependents of regular employees: For COMPLETE (all information required filled up, form signed, with complete attachments) application forms received by on-site nurse between the first (1st) and fifteenth (15th) day of the month, cover of dependents shall start on the first day (1st) day of the following month. For COMPLETE (all information required filled up, form signed, with complete attachments) application forms received by on-site nurse between the sixteenth(16th) and the 30th/ 31st day of the month, cover of dependents shall start on the sixteenth (16th) day of the following month. 6. Can my dependents be enrolled twice under the CVG plan (i.e. children enrolled by husband and wife who are both employees of CVG, parents enrolled by both siblings who are both employees of CVG)? No. Dependents may only be enrolled into the plan once. Usually, the employee with the higher benefit level enrolls his/her dependent. 7. What are pre-existing conditions? Any professional advice or treatment has been obtained for such illness or injury; or Illness or injury evident upon medical examination; or Natural history of illness or injury can be clinically determined to have started prior to any availment whether or not the member is aware of such illness or injury 8. Are pre-existing conditions covered under the plan? For employees: o You will enjoy PEC coverage up to 50% of your BENEFIT LIMIT, after six months from hire date. After one year of continuous membership, you will have PEC coverage up to 100% of your BENEFIT LIMIT. For dependents: o Members with no Pre-existing condition (PEC) coverage are entitled to a Php 5,000 annual coverage for emergency treatment in an Emergency Room of a hospital for PEC cases. 9. May I voluntarily pay more premiums to cover pre-existing conditions for new dependents? This shall not be allowed. 10. How do I access outpatient care? Out-patient services shall be availed in any of the accredited clinics of Intellicare except The Medical City satellite clinics and Healthway. Intellicare Page 2

3 11. What is the advantage of using Aventus clinics and Intellicare accredited clinics for outpatient care? Convenience Multi-specialty clinics are like one-stop shops for medical care. You need not go from one floor to another to undergo consults or diagnostic tests. Clinics are conveniently located for easy access. More efficient use of benefit pesos - You can maximize your Benefit Limit. For example: Actual services rates comparison for the case of Chronic Abdominal Pain Test Procedure Aventus Clinic Makati Medical Center Urinalysis Complete Blood Count Ultrasound (of the whole Abdomen) 2, , KUB IVP 4, , Actual comparison of rates of services (as of April 01, 2015) 12. What if I need a test that is not available in the clinic? Most procedures can already be done in multi-specialty clinics In the rare occasion that a member needs a prescribed test not available in the clinic (e.g. CT scan), the clinic personnel will refer the member to a hospital or the member may seek endorsement from the Intellicare Customer Service. 13. What about specialists? Multi-specialty clinics have doctors with different specializations. Some of these doctors also practice in hospitals. In the rare occasion that a member needs to consult a doctor with a specialization not available in the clinic, the member will be referred to a hospital. 14. What if I need to undergo a diagnostic exam to determine whether a condition is preexisting or not? (FOR DEPENDENTS) The dependent shall advance the cost of the exam first. If the result or condition is not preexisting, reimbursement can be filed through your site nurse. 15. What will happen if my total bill exceeds my Benefit Limit under the plan? What are the excess charges? What happens if I fail to pay the excess charges? Excess charges will be billed by hospital prior to discharge. If the hospital fails to charge these, you will receive a billing from Intellicare. Examples of Excess Charges: o Unfiled PhilHealth (or failure to file for PhilHealth prior to discharge) o Excess Room & Board, or other hospital expenses as a result of choosing a room beyond your limit o BENEFIT LIMIT exceeded o Excluded expenses (charges not included in the plan entitlement) Intellicare Page 3

4 Failure to pay for excess charges within ten (10) days from receipt of billing from Intellicare will result in SUSPENSION of coverage, i.e. exclusion from Network, and claims will be on hold. Intellicare Page 4

5 16. Can I upgrade to a higher benefit if I am willing to pay additional premium for that benefit level? This is not allowed because the benefits given by the company are based on the employee s job grade. 17. What if I choose a room higher than what I am entitled to? What if there was no room available within my limit? You will pay the room and board excess, the incremental cost which is roughly 30% of the total hospital bills and excess of the doctor s professional fee In cases of emergency confinement and your entitled room is not available, you may occupy a room 1 category higher (ex. From Regular Private to Large Private). Intellicare pays for the first 48 hours of the room upgrade (a proof/certification from the Admitting Section shall be provided). If your entitled room becomes available within the first 48 hours, you must transfer to avoid paying the excess charges. Extra charges for voluntary upgrade, involuntary upgrade beyond 48 hours and upgrade to Suite Accommodation shall be shouldered by the member. 18. What happens if the hospital has cash basis policy? There are few hospitals that have a cash basis policy for some procedures even if performed or recommended by an accredited physician. In cases like this, the member shall advance the cost first and file a reimbursement afterwards. Intellicare will reimburse based on HMO rates. At the moment, all care with accredited neurologists are on a cash basis policy only therefore reimbursement can be filed. Notwithstanding this, you still need to obtain a referral to go to an accredited neurologist. 19. What if there is no Intellicare doctor available in any accredited hospital for the field of specialization I need or I am referred to? What if an Intellicare physician bills beyond HMO rates? Intellicare will exert all effort to negotiate for Intellicare rates to be charged. If the physician does not agree, then you will advance the full amount due and will be reimbursed based on Intellicare rates. In no case should you negotiate rates directly with the physician. Let Intellicare handle the negotiation. At the moment, all care with accredited neurologists are on a cash basis policy only. Notwithstanding this, you still need to obtain a referral to go to an accredited neurologist. 20. What about medical emergencies? In emergency situations, members may proceed directly to the Emergency Section of the nearest hospital without going to a clinic. Emergencies are defined as: o Sudden and unexpected medical conditions that may lead to death or disability if immediate care is not received Intellicare Page 5

6 o Accidental injuries that cause severe pain and discomfort (Examples: heart attack, coma, stroke, poisoning, fainting, diarrhoea with severe dehydration, loss of consciousness or respiration, convulsion, vertigo) The decision whether the case shall be considered as emergency or not will depend on the judgment of the ER physician / Nurse on duty. 21. When and how do I file my PhilHealth form? Always file PhilHealth prior to discharge (even for some special out-patient procedures) For both accredited and non-accredited hospitals You will pay for PhilHealth portion if you fail to file. 22. Where can I view the benefits I could avail for myself and my dependents? A benefit manual may be downloaded from the portal ( 23. What if I want to give feedback on my experience with Intellicare? Log in to Under Contact Us, select Us and type your inquiry or feedback in the Message Box You can also us directly at convergys@amd.intellicare.net.ph Intellicare Page 6