PROVIDER MANUAL. Effective: August 2013

Transcription

1 PROVIDER MANUAL Effective: August 2013

2 1. How to recognise a Now Health customer 1.1 Membership card All WorldCare members receive a membership card with their unique membership number. All our membership cards carry clear information on what our customers are covered for. Each card shows: The WorldCare product option Any additional options The member s name Their unique membership number The expiry date of the plan The out-of-network excess or deductible Any out-patient co-insurance WorldCare product options There are four possible WorldCare product options. These four levels indicate the level of cover each customer should receive. They are: WorldCare Essential: In and day-patient care plan WorldCare Advance: In, day and out-patient care plan WorldCare Excel: In, day and out-patient care plan with routine and complex dental care WorldCare Apex: In, day and out-patient care plan with routine and complex dental care and routine maternity care Page 2

3 WorldCare additional options Please look out for the following options on members membership cards as it may affect what they are covered for. Enhanced Essential If the customer has this indicated on their card, and there is no Out-Patient Direct Billing mentioned on the card, the customer should pay you in full for Out-patient treatment Out-Patient Direct Billing Nil Excess If the customer has this indicated on their card, you can bill us directly. The customer should not pay an excess. Out-Patient Direct Billing with Co-Insurance The customer can elect to pay a 20% co-insurance on out-patient charges. If this is indicated, please remember to charge this additional fee. If it has not been selected, the card will state Nil HK Hospital Room Restriction If the customer has this indicated on their card, if they are hospitalised in Hong Kong, they should be allocated a semi-private room HK & PRC Hospital Room Restriction If the customer has this indicated on their card, if they are hospitalised in Hong Kong, they should be allocated a semi-private room. If they are hospitalised in China, they should be allocated a private room, an additional 15% co-insurance with an out-of-pocket limit of $7,500 is applicable when seeking treatment in the following: Shanghai United Family Hospitals and Clinics Beijing United Family Hospital and Clinics Parkway Health's Specialty & Inpatient Center Shanghai (Luwan) Parkway Health's Gleneagles Medical & Surgical Center Shanghai Maternity Benefit on Direct Billing xx% Co-Insurance If the customer has this indicated on their card, you can bill us directly. If customer has coinsurance for Maternity, it will be indicated on the card Page 3

4 Membership card examples Every member of Now Health has his or her own membership card, designed to carry clear information on what customers are covered for. Members covered by our Asia Pacific, UAE, Europe and Rest of World branches receive membership cards similar to this: Page 4

5 On the Card Front 1 Any benefit you might need to know about will be listed clearly in the top right hand corner of the card: such as * Out-Patient Direct Billing Nil Excess * Out-Patient Direct Billing USD 15 deductible per visit * Out-Patient Direct Billing AED 50 deductible per visit * HK Hospital Room Restriction * HK & PRC Hospital Room Restriction * Direct Billing for Maternity xx% Co- Insurance On the Card Back 8 How to get in touch with Now Health online 2 The product name and option 9 All of the Now Health customer service telephone numbers 3 The member s name 10 All of the Now Health 24-hour Emergency Assistance telephone numbers 4 The member s membership number 11 The mailing address of the Now Health office nearest to the member 5 The expiry date of the current plan year in dd/mm/yyyy format 12 A photograph of the member 6 The out-of network excess. This is the amount the member should pay towards the cost of their treatment when they go outside the network and for In-patient and Day-patient treatment within network 7 If the member has chosen the coinsurance out-patient charges option, it will note the amount of the coinsurance here (20%) 13 The logo of the underwriter of the member s plan Page 5

6 Members without out-patient benefits and covered by our China admitted product receive membership cards similar to this: Members with out-patient benefits and covered by our China admitted product receive membership cards similar to this: Page 6

7 Verification of Now Health membership a) Please verify that members are in possession of a valid Now Health Membership card entitling them to Direct Billing. b) Out-Patient Direct Billing Excess / Deductible per visit will appear on top right corner of the Now Health Membership Card. For the avoidance of doubt, if the Out-Patient Direct Billing is not mentioned in the Now Health Membership Card then the member has to pay and claim from Now Health directly for Out-patient treatment c) Please verify the amount of Co-insurance (for all services or for maternity) and Excess (for in-patient only), which is shown at the bottom right hand corner of the Now Health Membership Card. d) Please also verify the identity of the member against the Now Health Membership Card by requesting an original ID card i.e. driving license, or passport. e) Please verify that members are holding a valid membership card at the date of such treatment. The expiry date appears on the bottom left hand corner. Under no circumstances shall you hold Now Health liable for costs in respect of any Covered Services provided to a member more than five [5] working days after Now Health has notified you (in writing, by fax or by ) of the cancellations or suspension of the Covered Services in respect of that member f) Maternity on Direct Billing will appear on top right corner of Now Health Membership Card. If Maternity on Direct Billing is not mentioned on the card, member has to pay and claim for Out-patient treatment related to Maternity g) Now Health does not provide below services on direct billing unless there is any special prior arrangement made Out-patient treatment for Maternity (unless Maternity on Direct Billing is mentioned on the card) Out-Patient Dental Any treatment relating to Alternative Medicines Vaccinations Optical Wellness Benefit Out-patient Psychiatry Treatment Vitamins, Minerals and Organic substances (for any medical condition including Maternity) Please contact Now Health if you have any queries Page 7

8 2. Now Health forms: 2.1 A Now Health WorldCare Claim Form is available on the web at for download. A copy of the Claim Form is attached with this manual. In some regions (e.g. UAE etc) provider is allowed / required to submit e-claims (This should be done once agreed between provider and Now Health) 2.2 A Now Health WorldCare Pre-Authorisation Request Form is available on the web at for download. A copy of the Pre- Authorisation Request Form is attached with this manual. Except in cases of Emergency as defined in this Agreement the Provider shall seek prior authorisation from Now Health for the following: a) All In-patient admissions and/or treatment b) All pre-planned Day-patient treatment c) All pre-planned surgery d) In-patient / Day Patient treatment related to pregnancy and/or Maternity e) Diagnostic procedures- CT / MRI Scan, PET (Positron emission tomography) Scan f) Chemotherapy, Radiotherapy, Endoscopies (Gastroscopy, Colonoscopy, Sigmoidoscopy) g) In-patient psychiatric treatment h) Evacuation and repatriation i) Mortal remains j) Physiotherapy k) Nursing care at home l) AIDS m) USA elective treatment n) Medicines for more than 3 months duration o) Medicines cost exceeding USD 1000/- Requests for prior authorisation of Treatment must be submitted in writing, by fax or , and shall be accompanied with a cost estimate; In addition to the cases set out above the Provider must seek confirmation from Now Health where any uncertainty exists whether the Treatment proposed is covered; Now Health will issue a Treatment authorisation confirmation with details of Beneficiary s Plan, any limitations, exclusions and co-payments applicable to the Plan; Authorisations are only valid for the treatment requested and where confirmed and agreed by Now Health in writing; If the diagnosis, scope or type of Treatment changes after an authorisation has been issued, the Provider must seek a revised authorisation from Now Health; If the Provider treats a Beneficiary without the necessary prior authorisation from Now Health or treats a person who is not covered under a valid Plan then the Provider shall not obtain payment from Now Health for any non-covered services; Page 8

9 For all enquiries related to Pre-Authorisation and Guarantee of Payment, please contact Now Health Clinical Team for assistance 2.3 Guarantee of payment form Guarantee of payments (GOP) are issued only for the proposed treatment after you have submitted the Pre-Authorisation request. A GOP is valid for 14 days. Should the diagnosis or scope of treatment change, please inform us immediately. We will review the new information and issue an updated GOP. A sample copy of the GOP is attached with this manual. Page 9

10 3 Claims submission procedure: 3.1 Direct claims procedure The Provider shall submit claims for healthcare services provided to Now health Beneficiaries in the manner and format as specified below Provider should submit all claims incurred by Now Health members within 30 days from the end of the month in which healthcare services were provided. If there is any delay in the submission of claims, please notify Now Health and include the reason for the delay. The claims should sent by mailing the original claims documents to Claims Department of respective Now Health office Now Health agrees to process valid claims no later than 30 days after receipt. A full breakdown of claims paid, pending and rejected will be provided to you for reconciliation purposes. A claim should consist of fully itemised invoices with supporting documentation. Kindly submit the claims in batches, with a separate statement of account for each batch. An invoice should be generated clearly mentioning the following: The name of your organisation Invoice number Date of treatment Name of member as it appears on the Now Health International card Now Health International card number The services rendered, their unit prices, together with the discount given The amount collected from the member for each service provided, if any Total of the amount claimed (after deduction of discount and/or copayment collected from the member, if any) Total of amount collected from the member, if any. Page 10

11 Invoice Details-Example PROVIDER NAME Invoice No: Date of Treatment: Member Name: Now Health International Card No: Payer: Sr. No Service Item Gross Amount Discount % Member Share Net Amount 1 Consultation % X-ray Chest 80 25% CBC 60 25% 0 45 Total The above example is for your reference only. You are free to customise the appearance of your invoices at will as long as it contains the abovementioned information. The claim should be submitted with the following documents - Original invoice Now Health International Claim Form - The treating physician needs to complete the relevant Now Health International Claim Form in detail clearly mentioning the diagnosis, etiology, assessment etc. The claim form submitted must bear the treating physician s stamp and signature. The practitioner s stamp must clearly state his/her license number. The Now Health International claim form MUST be signed by the member receiving treatment or the parent/legal guardian in case of minors. In case of emergency a next in kin may also sign on the member s behalf. Original Prescription if medicines have been dispensed (except for controlled medicines). Reports of any investigation carried out on the member Copy of approval (if treatment requires pre-approval) In case of hospitalisation reports of the daily investigations carried out on the member, operation notes (together with the start and stoppage times of the operation), discharge summary etc. In case of Physiotherapy, each session should be invoiced separately All disputed claims, including declined invoices should be resubmitted (with a maximum of two attempts) to Now Health within 30 calendar days from the date of receipt of payment and /or receipt of remittance advice. If the provider is late in submitting these, Now Health has the right to reject payment of the claim. Page 11

12 3.2 Reconciliation Missing Document: If supporting documents that are required to process the claim are missing, we will notify you in writing. You are requested to submit any missing document(s) to us with a covering letter, specifying the claims reference number very clearly on all documents. We allow a maximum period of 30 days for the submission of missing documentation from the date we notify you in writing. This will be discussed in the quarterly reconciliation/settlement meetings. 4. Accommodation type: Now Health members are eligible to a single standard private room. However, please note that for HK and PRC residents who are hospitalised in Hong Kong, hospital accommodation may be limited to semi-private room if such option was chosen by the member. Page 12

13 Exclusions: What we do not cover? 1. Any co-insurance due by the member as notified by Now Health. 2. Any alternative medicines except: Dietician s Consultation, Traditional Chinese Medical Practitioner s Consultation, Chiropractic Treatment, Osteopathy, Homeopathy & Acupuncture when referred by a Medical Practitioner or Specialist up to a maximum of 15 sessions per period of cover. 3. Treatment received after the Valid to date, as shown on the Participant s card. 4. Basic immunisation and booster injections that are NOT required under the regulation of the country where treatment is given and which is NOT medically necessary travel vaccinations and malaria prophylaxis. 5. Act of Terrorism, war and illegal acts Treatment of any condition resulting directly or indirectly from, or as a consequence of war, acts of foreign hostilities (whether or not war is declared), civil war, rebellion, revolution, insurrection or military or usurped power, mutiny, riot, strike, martial law or state of siege, or attempted overthrow of government, or any acts of terrorism, unless the members are an innocent bystander. 6. Administrative and shipping fees Any charges for filling in claim forms or providing medical reports. The cost of shipping (including customs duty) on transporting medication. 7. Alcohol and drug abuse Treatment resulting from dependency on or abuse of alcohol, drugs, or other addictive substances and any illness or injury arising directly or indirectly from such dependency or abuse. 8. Chemical exposure Treatment costs directly or indirectly caused by or contributed to or arising from: ionising radiations or contamination by radioactivity from any nuclear waste from the combustion of nuclear fuel; the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof. 9. Cosmetic surgery Treatment costs relating to cosmetic or aesthetic treatment or any treatment related to previous cosmetic or reconstructive surgery (whether or not for psychological purposes), such as but not limited to acne, teeth whitening, lentigo and alopecia. 10. Contamination Treatment of any conditions, or for any claim arising directly or indirectly from chemical or biological contamination, however caused, or from contamination by radioactivity from any nuclear material whatsoever, or asbestosis, including expenses in any way caused by or contributed to by an act of war or terrorism. 11. Dental care Any dental care unless these Benefits are included on the Certificate of Insurance. However Now Health International will pay for Emergency In-Patient dental treatment following an accident as detailed in the Benefit Schedule. Page 13

14 12. Developmental disorders Treatment of developmental, behavioural or learning problems such as attention deficit hyperactivity syndrome, speech disorders or dyslexia and physical developmental problems. 13. Dietary supplements Naturally available substances that can be purchased without prescription, including but not limited to vitamins, minerals, and organic substances. 14. Eating disorders Treatment of eating disorders such as, but not limited to, anorexia nervosa and bulimia. 15. Co-Insurance Any co-insurance due by the members as indicated on the membership card 16. Excess Fees Any excess fee due by the members as notified by Now Health 17. Experimental Treatment and drugs Treatment or drugs which have not been established as being effective or which are experimental. For drugs this means they must be licensed for use by the European Medicines Agency or the Medicines and Healthcare products Regulatory Agency and be used within the terms of that licence. For established treatment, this means procedures and practices that have undergone appropriate clinical trial and assessment, sufficiently evidenced and published medical journals and/or been approved by the National Institute for Health and Clinical Excellence for specific purposes to be considered proven safe and effective therapies. 18. Eyes and ears Routine eyesight or hearing tests or the cost of eyeglasses, contact lenses, hearing aids or cochlear implants. Eye surgery to correct vision, however eye surgery to correct an Eligible Medical Condition is covered. 19. Foetal surgery The costs of surgery on a child while in its mother s womb. 20. Genetic testing The cost of genetic tests, when those tests are undertaken to establish whether or not the members may be genetically disposed to the development of a Medical Condition. 21. HIV, AIDS or sexually transmitted disease Treatment for Acquired Immune Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARCS) and all diseases caused by or related to Human Immunodeficiency Virus (HIV) (or both) and sexually transmitted disease. 22. Morbid obesity Treatment for, or related to, morbid obesity. Treatment costs arising from or relating to removing fat or surplus healthy tissue from any part of the body. 23. Nursing homes, convalescence homes, health hydros, and nature cure clinics Treatment received in nursing homes, convalescence homes, health hydros, nature cure clinics or similar establishments. For convalescence or where the member is in hospital Page 14

15 for the purpose of supervision. For extended nursing care if the reason for the extended nursing care is due to age related infirmity and/or if the hospital has effectively become the home of the member. 24. Pregnancy or maternity Treatments relating to normal Pregnancy or childbirth, voluntary caesarean section, unless 1) For In-patient / Day Patient covered if approved by Now Health International 2) For Out-patient covered if Maternity on direct billing is mentioned on membership card 25. Professional sports Any costs resulting from injuries or illness arising from any form of professional sport. By professional sport, it means where the member is being paid to take part. 26. Reproductive medicine Investigations into or treatment of infertility and fertility, sterilisation (or its reversal) or assisted conception. You are not covered for the costs in connection with contraception. 27. Routine examinations, health screening Routine medical examinations including issuing medical certificates, health screening examinations or tests to rule out the existence of a condition for which the members do not have any symptoms. 28. Second opinions The costs of any second or subsequent medical opinions from a Medical Practitioner or Specialist for the same Medical Condition other than stated in the Certificate of Insurance, unless authorised by Now Health International. 29. Self-inflicted injuries or attempted suicide Any costs for treatment resulting directly or indirectly from self-inflicted injury, suicide or attempted suicide. 30. Sexual problems and gender re-assignment Treatment costs relating to sexual problems including sexual dysfunction or gender reassignment operations or any other surgical or medical treatment including psychotherapy or similar services which arise from, or are directly or indirectly associated with gender re-assignment. Treatment costs for sexually transmitted infections. 31. Sleep disorders Treatment costs related to snoring, insomnia, jet-lag, fatigue, or sleep apnoea including sleep studies or corrective surgery. 32. Travel/accommodation costs Transport or accommodation costs incurred during trips made specifically to get medical treatment unless these costs are for an Emergency medical Evacuation that Now Health International pre-authorises. Any costs of Emergency medical Evacuation or repatriation that Now Health International did not pre-authorise and arrange. 33. Travelling against medical advice Not covered for medical or other costs if the member travels against the advice given by the treating Medical Practitioner. Page 15

16 34. Treatment by a family member Not covered for the costs of treatment by a family member or for self-therapy. 35. Treatment charges outside of our reasonable and customary range Treatment charges when they are above the Reasonable and Customary Charges level. 36. External Prosthesis Any costs relating to providing, maintaining and fitting of any external prosthesis or appliance or other equipment, medical or otherwise. Page 16

17 Now Health International contacts: Middle East & Africa Now Health International, PO Box , Al Shaiba Building, Dubai Outsource Zone, Dubai, UAE Tel: +971 (0) Fax: +971 (0) /1490 Please call the following numbers in case of non-emergencies: Sunday to Thursday (9am 5pm): +971 (0) Out of office: +971 (0) Europe Now Health International (Europe) Limited, Suite G3/4, Coliseum Building, Watchmoor Park, Camberley, Surrey, GU15 3YL, Surrey, UK. Tel: +44 (0) Fax: +44 (0) Please call the following numbers in case of non-emergencies: Monday to Friday (9am 5pm): +44 (0) Out of office non emergency: +44 (0) Asia Pacific Now Health International, Suite B 33/F, 169 Electric Road, North Point, Hong Kong. Tel: Fax: Please call the following numbers in case of non-emergencies: Monday to Friday (9am 5pm): Out of office non emergency: China Now Health International (Shanghai), Room ,11/F, BM Tower, No. 218 Wu Song Rd, Hongkou District, Shanghai , China Tel: Fax: Please call the following numbers in case of non-emergencies: Monday to Friday (9am 6pm): Out of office non emergency: Page 17

18 Hour Medical Assistance Now Health has designated Axa Assistance as the 24 hour Medical Assistance Company in the event where a medical condition of the member requires Emergency transportation to a different medical facility, as defined within the benefits section of the terms and conditions of a beneficiary plan. The contact details for AXA Assistance are: Middle East and Africa: +971 (0) Europe: +44 (0) Asia Pacific: Page 18

19 7. Appendices: Appendix 1 Now Health WorldCare Claim form Page 19

20 Appendix 2 Now Health Pre-Authorisation Form Page 20

21 Appendix 3 Sample copy of GOP Page 21