CLAIMS SUBMISSION PROCESS

Transcription

1 CLAIMS SUBMISSION PROCESS Part 4: Differences Between ECP And LOG ECP LOG Guarantee amount No Yes Pre-Approved No Yes Hospital to contact AIA Yes No There is a time frame to revert to hospital Yes (within 24 hrs) No B: GENERAL QUESTIONS Q1: What are the help available if insured needs assistance with claim matter? ANS: If insured needs our assistance with claim matter, please do not hesitate to contact our Helpdesk Hotline at or us at sg.eb.claims@aia.com. Q2: Is if all prescribe medical items are payable under group policy? ANS: Please note that the group policy may not response to all prescriptions by the doctor, but subject to the policy terms & conditions. The doctor may prescribe what he deem necessary in his professional medical opinion but it may not be covered under the medical plan. Please take note that the policy only extend coverage to drugs / medication. GHS Claim: Q1: What is our turnaround time to reimburse insured upon receipt of full claim documents? ANS: Insured will be notified on the status of claim within 2 working weeks upon receipt of full claim documents. Member can expect the reimbursement within next 7 working days after the approval date. If you do not hear from us, please us (sg.eb.claims@aia.com) with a scan copy of the claim documents, if possible. Q2: How does AIA reimburse if Medisave and/or Shield is/are used? ANS: AIA will reimburse insured in the sequence of hospital (if LOG/ECP is used), cash, Medisave and Shield plan.

2 Q3: Can I claim for medical report fees? ANS: If the claim is payable and insured admission is to a Government Restructured Hospital, AIA will reimburse the said medical report fees up to S$80. The maximum benefit shall be included in the total of the maximum Other Hospital Services Benefit. No reimbursement for admission to a Private Hospital/Specialist Clinic. Q4: Part of the hospitalization bill may be paid from my Medisave account. Can I claim for the amount that was deducted from my Medisave account? ANS: You can claim from AIA for any medical items payable, within your plan entitlement and is not under the list of exclusions, with the submission of the completed Group Hospital & Surgical claim form, and original finalized hospital bills. AIA will assess your claims and for the amount that has been deducted from your Medisave account and is reimbursable, AIA will reimburse directly the amount back to your Medisave account via CPF. Q5: What happen to a declined claim? ANS: A rejection letter and a complete set of CTC of claim documents will be sent out within 2 working days. We can only provide CTC copies which are as good as original as they will carry our stamp "Document Printed From AIA Imaging Workflow System" in red colour serving to alert that AIA has implemented Imaging & Workflow system and this is a CTC copy printed from AIA system. If member is seeking reimbursement from another insurer or from their HR, they would need to submit the CTC tax invoice as supporting documents. Q6: How we determine the surgical benefit for each claim? ANS: Surgical benefit under GHS policy is meant to cover the actual charges made for any surgical operation performed by one or more Registered Medical Practitioners. Surgical percentage according to surgical schedule of fees applies for surgeries at: - Private hospitals - Government restructured hospital, where Room & Board (R&B) entitlement is exceeded The medical staff at hospital provides the surgical code for the surgical procedures & AIA will match the code with the surgical schedule of fees to get the percentage. The surgical benefit limit per each operation / per condition is subject to the amount obtained by multiplying the appropriate percentage shown for that operation in the Surgical Schedule of Fees by the maximum Surgical Benefit. All medical institutes are governed by the medical code and ethics. There is a professional medical guide used by hospitals that provide the list of surgical codes for purpose of insurance claims. The Surgical Schedule of Fee used by AIA is approved by Life Insurance Association (LIA).

3 Q7: Member is going to be admitted for a surgery. Is if fully claimable? ANS: 1) Government Restructured Hospital: If you are admitted to a Government Restructured Hospital, and stay within your Room & Board (R&B) entitlement, the surgical fees will be lump sum under a lump sum amount (H47) Hospital benefit (if any). Please note however, that other miscellaneous administrative and nonmedical related items will not be payable. If you are admitted to a Government Restructured Hospital, and exceed your Room & Board (R&B) entitlement, a surgical percentage will be applied on your maximum surgical benefit, which will be the maximum payable for surgery fees. Other items that will not be payable under the policy are miscellaneous administrative and non-medical related items. 2) Private Hospital: If you are admitted to a Private Hospital, a surgical percentage will be applied on your maximum surgical benefit, which will be the maximum payable for surgery fees. Other items that will not be payable under the policy are miscellaneous administrative and non-medical related items. Q8: Is hospitalization incurred at overseas covered? ANS: Yes. The GHS policy provides 24-hour worldwide coverage. The limit claimable is subject to the employee s benefits entitlement. Please note that the reimbursement amount will be in Singapore dollars, with the exchange rate based on the claim incurred date. Q9: Who determines the surgical code? ANS: All medical institutes are governed by the medical code and ethics. There is a professional medical guide used by hospitals that provide the list of surgical codes for purpose of insurance claims. The medical staff at the hospital provides the surgical code. Q10: How do we know that the Surgical Schedule of Fees used by AIA is approved? ANS: All insurers policies terms and conditions are guided by Life Insurance Association. This goes for the Surgical Schedule of Fee used by AIA, which is already approved by LIA. Q11: How are we sure that the percentage apply by AIA is correct? ANS: As an insurance provider, AIA is being audited by professional audit firms on an annual basis. The claims processed are being audited. Q12: For claims submission, must the hospital bill be final and itemized? ANS: Yes. Final hospital bill will reflect the final amount incurred by you and the amount deducted from your Medisave account and/or Medisave-approved Shield plan. The final hospital bill will provide breakdown of cost of services/treatment rendered to you. AIA will assess the amount reimbursable according to the employee s benefits entitlement.

4 Q13: How can I tell if the hospital bill is a final bill or not? ANS: For final hospital bill of Singapore Government/Restructured hospitals, the amount deducted from Medisave and/or Medisave-approved shield plan will be reflected on the bill. For final hospital bill of Singapore private hospitals, wordings of Tax Invoice and amount deducted from Medisave and/or Medisave-approved shield plan will be reflected on the bill. Q14: How will insured be notified of his/her claim status? ANS: An Explanation of Benefit/Request for additional documents letter will be attention to you via company address. Outpatient Claim: Q1: Does enrolled child(ren), who are currently visiting the Paediatrician need a referral letter from the Panel GP to continue the visit? (Provided insured is entitling to Specialist Outpatient Benefits) ANS: Yes, the enrolled child(ren) need to get a referral letter from a Registered Medical Practitioner in order to continue visiting the Pediatrician. Referral letter must be issued at the recommendation of the Registered Medical Practitioner. Q2: Will the cost of referral letter given by the Panel GP be charged to the insured member? ANS: No, if the referral letter is issued at the recommendation of the Panel GP, the cost will be borne by AIA. Q3: If the insured member did not produce/bring the IHS card to visit a panel clinic, can the medical claim be reimbursed? ANS: Insured member must present the IHS card to enjoy cashless service and treatment at the Panel clinics. If insured is unable to provide a valid IHS card and upfront payment made during the panel visit, the claim might be appealed under non-panel reimbursement rate at the maximum Benefit set forth in the Policy Schedule. This is because that the clinic provides a corporate rate for patients with IHS card. Without the presentation of IHS card, the clinic charges the patients with the usual walk-in rate. Q4: Why are surcharges incurred due to visits outside the normal operating hours of the clinic excluded under Outpatient Clinical (Fullerton)? ANS: The surcharges charged by clinics vary. Outpatient Clinical (Fullerton) pays for basic medical costs incurred during the normal operating hours. Q5: If I encounter any administrative issue at the Fullerton panel GP clinic, what are the help available? ANS: If insured encounters any administrative issue at the Fullerton panel GP clinic, insured may advise the clinic assistant/administrator to contact Fullerton for clarification at DID during office hours.

5 Q6: If insured is unable to obtain cashless service at the Fullerton panel GP clinic upon presenting with a valid IHS card due to unsuccessful verification, can he/she seeks reimbursement? ANS: Yes, the insured member is required to submit such claim to AIA for reimbursement, subject to the policy terms and conditions. Q7: How frequently is the Fullerton panel GP clinic listing updated? ANS: The Fullerton panel GP clinic listing is updated on a half-yearly basis (Jan and Jul). Insured member may view the updated listing via AIA ebenefits portal. Q8: Can insured get his/her current Specialist / Pediatrician to write him/her a medical report instead? Can insured claims the cost of such report from AIA? ANS: No, such costs incurred will not be paid by AIA. Q9: What is the validity of a referral letter? ANS: The first visit to a Specialist must be done within 3 months from the date of the GP referral letter. For subsequent follow-up with the same Specialist for the same medical condition, it can be done within 12 months from the date of the last Specialist visit. Q10: Does insured need to obtain a referral letter before visiting A&E? ANS: No, referral letter is not required when visiting A&E. But the situation must be due to Emergency.