PMCARE SDN BHD

pmcare sdn bhd working guidelines for pmcare panel of hospital & specialist clinics chapter 1 effective date: 24/06/2016, revision 8 1 1.1 introductio...

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PMCARE SDN BHD WORKING GUIDELINES FOR HOSPITALS AND SPECIALIST CLINICS

TABLE OF CONTENT ITEM

PAGE

CHAPTER 1:

1

1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15

1 1 1 1 1 1 2 2 2 2 2 2 2 2 3

Introduction Hospital & Specialist Clinic Address Provider Code Identification of PMCare Member Verification of PMCare Member Medical Record Exclusions Charges Claims Submission Submission Deadline Deductions From Amount Claimed Appellant Temporary Suspension of Service Termination Communication

CHAPTER 2: CONSULTATION AND ADMISSION PROCEDURES

4

2.0 2.1 2.2

5 5 5

Provision of Services For PMCare Members For PMCare Premier Card Holder

CHAPTER 3: BILLING AND DISCHARGE PROCEDURES

6

3.0 3.1 3.2

7 7 7

Guides on Discharge Procedures For PMCare Members For PMCare Premier Card Holder

CHAPTER 4: CLAIMS SUBMISSION PROCEDURES

8

4.0 4.1 4.2 4.3

9 9 9 9

Claims Submission Procedures Submission Deadline And Requirements Documents and Information Required for Claims Submission for Reimbursement PMCare Premier Card Holder

CHAPTER 5: EXCLUSION LIST

10

5.0

11

Exclusion List

APPENDIXES: APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX

1: 2: 3: 4: 5: 6: 7: 8: 9:

Sample of PMCare Membership Cards/Medical Logbook PMCare Pre-Admission Guarantee Letter (“GL”) Request for Extended Admission GL Form Guarantee Letter Request Denied Consent Form Discharge Advice (“DA”) Confirmation of Receipt of Medical Claims Invoices Directory for Medical Department Staff

12 & 13 14 & 15 16 - 23 24 & 25 26 & 27 28 & 29 30 & 31 32 - 34 35 & 36

PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINICS CHAPTER 1 1.1

INTRODUCTION The Working Guidelines is issued with the intention to provide clear description of the working arrangement between panel of Hospital or Specialist Clinics and PMCare. Both parties are required to observe and comply with the Working Guidelines. Kindly take time to familiarize yourself with the Working Guidelines, which should also be made as reference for your daily operation. Whilst every effort has been made to ensure the Working Guidelines is complete, comprehensive and simple, it is still subject to further improvement and revision from time to time for which, you will be informed. Lastly, we will also appreciate any feedback on the Working Guidelines from you.

1.2

HOSPITAL OR SPECIALIST CLINIC ADDRESS During the term of appointment you shall operate at the appointed address. If there is any change in the premise address, you are required to notify us in writing 1-month prior to the intended change. We reserve the right to terminate your appointment on the panel if for any reason to us; we find that the intended new business location is unsuitable for our business arrangement.

1.3

PROVIDER CODE Your Hospital or Specialist Clinic shall be given a PMCare Provider Code, which shall be specified in your appointment letter. Please note that the provider code is exclusive to the appointed Hospital or Specialist Clinic, and shall not be used to represent any other branch or affiliated Hospital or Specialist Clinic. The provider code shall help to facilitate communication and administer the business arrangement between the Hospital or Specialist Clinic and PMCare.

1.4

IDENTIFICATION OF PMCARE MEMBER Member shall produce his/her PMCare Medical Card or Identification Card in order to seek assistance from specialist/hospital to request for a Guarantee Letter prior seeking treatment or service.

1.5

VERIFICATION OF PMCARE MEMBER Please verify member’s identification against another documents (i.e. Identification Card or passport or Guarantee Letter)

1.6

MEDICAL RECORD Your Hospital or Specialist Clinic shall maintain record of every PMCare Members seen and treated and obtain consent for the release of medical information for each visit by requesting the Member or the guardian (for minor) to sign a note of consent. Your record shall include the following: i) Member/Patient name and details ii) PMCare membership number iii) Date and time for each visit iv) Consent for the release of medical information v) Medical condition vi) Treatment and service rendered vii) Results of diagnostic tests and procedures, if any viii) Note on referral, if applicable

Effective Date: 24/06/2016, Revision 8

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINICS CHAPTER 1 We reserve the right to review the abovementioned Hospital or Specialist Clinic records for verification of claims. Your Hospital or Specialist Clinic shall provide to us on site review and/or submit to us copy of record for the purpose. 1.7

EXCLUSIONS Member healthcare benefit under PMCare program is subjected to exclusions (refer to List of Exclusion - Chapter 5). Please familiarize yourself with the exclusions and refrain from providing them.

1.8

CHARGES You should be guided by the agreed schedule of charges under the appointment to PMCare Panel of Hospital or Specialist Clinic, MMA Schedule of Fees and the Thirteenth Schedule in the Private Healthcare Facilities and Services Act (1998), and Regulations and Order, whichever is lower when invoicing for services provided to our members. You are also required to provide details of services provided together with their respective charges.

1.9

CLAIM SUBMISSION Invoices (claims) must be submitted to reach us within thirty (30) days from the service date or date of discharge.

1.10

SUBMISSION DEADLINE Kindly ensure accuracy and submit claims within thirty (30) days from the service date or date of discharge. PMCare shall not be obliged to accept and pay claims that are submitted late i.e. beyond 30 days.

1.11

DEDUCTION FROM AMOUNT CLAIMED Deduction of RM2.00 MEPS-IBG charge or RM8.00 RENTAS charges shall also be made by the bank for the payment made by PMCare via MEPS-IBG or RENTAS. Deduction might be made to reflect any legitimate and effective charges applied by a financial institution or equivalent in the transfer of payment made by or through it.

1.12

APPELLANT If there is any grievance on matters related to the panelship arrangement by either party, the Hospital/Specialist Clinic or PMCare shall give written notice to the other party, giving the respondent seven (7) days to respond.

1.13

TEMPORARY SUSPENSION OF SERVICE Both the Hospital or Specialist Clinic and PMCare may suspend the panelship appointment for a temporary period of time by giving either party fourteen (14) days written notice before the suspension.

1.14

TERMINATION Either party, the Hospital/Specialist Clinic or PMCare can terminate the panelship appointment by giving thirty (30) days notice prior the termination. PMCare also reserves the right to terminate your panelship when we deem necessary without obligation of providing reason.

Effective Date: 24/06/2016, Revision 8

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINICS CHAPTER 1 1.15

COMMUNICATION Please direct any enquiries, complaints or any form of feedback directly to PMCare and not to our clients, be it its employees and/or dependents. Kindly communicate with our Provider Network Executive or Medical Director for any inquiry (refer to Appendix 9 – Directory for Medical Department). Your email address would be greatly facilitating communication between both parties. Remember to quote your Provider Code each time communicating with us.

Effective Date: 24/06/2016, Revision 8

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CONSULTATION AND ADMISSION PROCEDURES

2.0

PROVISION OF SERVICES 2.1

FOR PMCARE MEMBERS 2.1.1 2.1.2 2.1.3

2.1.4 2.1.5 2.1.6 2.1.7

PMCare members must produce their PMCare membership card for identification (Refer Appendix 1). Check against NRIC for confirmation that he/she is the valid member. PMCare member must produce a PMCare GL (Refer Appendix 3) to the registration personnel before seeking treatment. (In some cases, the GL has been faxed directly to the hospital, where the registration personnel shall retrieve it). If the member does not have a GL during a visit, the hospital must request for a GL from PMCare Careline on the same day treatment is given to the patient, BEFORE the consultation or admission. Please fax the patient’s referral letter (first visit), appointment card (follow up visit) or Pre Admission (admission case) before a GL can be issued. Patient or guardian shall sign on our GL-Part 1 for consent to release medical information to PMCare. Patient receives treatment and medication. The hospital shall then bill PMCare. Please refer to the Claim Submission Procedures (Page 8) to ensure the required documents are submitted for payment. Please refer to Page 12 for various samples of PMCare membership cards or logbooks.

Important Notes: 2.1.8

2.1.9

2.2

A Consultation GL cannot be used for an Admission. If the patient is required to be admitted after consultation, the hospital MUST request for an admission GL. Hospital is required to submit to PMCare Pre Admission Form which has been completed by the doctor including to estimate the cost in any treatment plan to be conducted. For sample of Pre Admission Form, please refer to Appendix 2. Validity of GL: 2.1.9.1 Consultation GL – valid for fourteen (14) days from date of issuance. 2.1.9.2 Admission GL – valid for fourteen (14) days from date of issuance and good for ten (10) days of stay. When an admission is about to exceed the 10-day limit or the limit amount set in the GL, the hospital must contact PMCare for advice on additional coverage. 2.1.9.3 GL for extension of admission - The hospital shall fax the itemized pro forma bill to show the current hospitalization bill of the member, together with duly filled up Request for Extended Admission GL Form (Refer Appendix 4). Once approved, PMCare shall issue the new GL for extension of stay based on the remaining balance of patient’s coverage (if any). If the request is not approved, PMCare shall fax Guarantee Letter Request Denied (Refer Appendix 5). 2.1.9.4 For EMERGENCY case, please attend to our members immediately and subsequently call PMCare to request for a GL.

FOR PMCARE PREMIER CARD 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6

Member must produce a valid PMCare Premier Card to the registration personnel. Member must sign a Consent Form (Refer Appendix 6) to release medical information to PMCare. This card can be used for both outpatient and inpatient treatment. Access to the hospitals shall be on direct access; referral letters are not required. The cardholder shall be provided treatment or service immediately by the hospitals without GL. (GL to be requested only after patient has left the hospital). Hospital is required to submit to PMCare the original itemised bill together with the Consent Form, which has been completed by the doctor for claims processing

NOTE: PMCare Premier Card is given to our VIP members only. Careline number: 03-8026 7799 Careline fax number: 03-8023 9999 Medibase: www.medibase.com.my SAMPLE

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BILLING AND DISCHARGE PROCEDURES

PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINIC CHAPTER 3 3.0

GUIDES ON DISCHARGE PROCEDURES 3.1

FOR PMCARE MEMBERS Hospital must fax the following documents to PMCare before patient is discharged:

3.2

3.1.1

Itemized bill (to be marked “For PMCare Confirmation”)

3.1.2

Part II of GL or other documents that provides diagnosis and/or procedures done, especially surgery.

3.1.3

PMCare will fax the Discharge Advice Form (Refer Appendix 7) upon confirming the itemized bills.

3.1.4

Hospital must collect from the patient any excess amount before patient leaves the hospital (Refer page 17, item 4[c] in the sample of GL).

3.1.5

Please discharge the patient and send us the claim for payment (Refer to Claims Submission Procedures – Page 8)

FOR PMCARE PREMIER CARD HOLDER

PMCare Premier Card 3.2.1

Hospital is not required to confirm the bills during discharge.

3.2.2

Hospital to send to PMCare the original itemized bill together with the Consent Form, which has been completed by the doctor for claim processing.

Effective Date: 24/06/16, Revision 8

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CLAIMS SUBMISSION PROCEDURES

4.0

CLAIMS SUBMISSION PROCEDURES 4.1

SUBMISSION DEADLINE AND REQUIREMENTS Invoices (claims) must be submitted to reach us within thirty (30) days from the service date or date of discharge.

4.2

DOCUMENTS AND INFORMATION REQUIRED FOR CLAIMS SUBMISSION FOR PAYMENT:

No.

Items

Inpatient Claims

Outpatient Claims

1 2 3

Original & Detail Invoice Guarantee Letter Part I Guarantee Letter Part II (Doctor’s Brief Note) Drugs/Medicine/Pharmacy details Descriptions of procedure done by each doctor Type of Surgery done by each doctor Medical supplies / Disposables Operation Theatre Supplies Descriptions of package (e.g. PTCA, Maternity etc) Descriptions of Implant / Medical Devices Descriptions of Laboratory Charges Descriptions of Special Diagnostic (e.g. X-ray, Ct Scan etc) Descriptions of Injections / Drips Descriptions of Miscellaneous Charges

FOR ALL CLAIMS

FOR ALL CLAIMS

4 5 6 7 8 9 10 11 12 13 14

We shall issue a “Confirmation of Receipt of Claims of Medical Claims Invoices” letter (Refer Appendix 8) informing you of the status of your claims and specifying whether the claims are received timely and/or completely (Refer page 32, 33 & 34). 4.3

PMCARE PREMIER CARD PMCare Premier card is issued to our VIP members for easy access to your hospital. PMCare is still required to process this category of claims for further submission to the insurer/paymaster for reimbursement.

We therefore take this opportunity to remind you that you are to ensure that your invoices with details information are submitted to us timely, accurately and also complete. Your invoices will not be payable by PMCare if this deadline and requirements are not fulfilled. Note: Service date = date the service was rendered.

.

9

EXCLUSION LIST

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINIC CHAPTER 5 5.0

EXCLUSION LIST The following items are not covered by the payers managed by PMCare Sdn Bhd unless stated otherwise in the GL: 5.1 5.2 5.3

5.4

5.5 5.6

5.7 5.8 5.9

5.10

5.11

5.12 5.13 5.14

5.15 5.16 5.17 5.18 5.19

5.20 5.21

5.22

AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS related complex), and all illnesses or diseases in the presence of the Human Immune-deficiency Virus (HIV). Non-medical services provided by a hospital such as radio, television, telephone, fax or similar facilities. Cosmetic surgery, cosmetic treatment, eye refraction, contact lens or any procedures to correct/alter refractive errors including prescription of glasses and contact lens and refractive surgery using laser or any other means or device, the acquisitions of prosthetic such as artificial limbs, and hearing aids except as necessitated by injuries occurring wholly during the period of coverage. Dental care treatment (unless covered by the dental package), filling, extractions including removal of impacted tooth and general dental care except dental operation resulting from an injury sustained by the Member in any accident. Disabilities of a newborn child contracted prior to or during birth or in the first 14 days thereafter. Mental illness and psychiatric disorders, self-inflicted injuries or attempted suicide, consequences of alcohol abuse, drug addiction, and treatment to improve the psychological, mental or emotional well being of the person covered. Congenital anomalies diagnosed or identified during or after birth or even at later age. Birth control, sexual dysfunction (i.e. Viagra), infertility investigation and treatment. Investigation and treatment (of condition) related to pregnancy, child birth (including surgical delivery), miscarriage, abortion and prenatal and postnatal care (unless covered by the maternity package). Third party requested Medical Examinations including pre-employment, insurance and routine physical examinations, tests not incidental to treatment or diagnosis of a covered disability, or any treatment which is not medically necessary including preventive treatment (including any circumcision whether or not related to illness or infection, voluntary sterilisation of either sex such as castration, vasectomy and tubectomy), preventive medicine (including elective adult immunizations), and treatment for obesity, weight reduction or weight improvement. Sickness or injury arising from racing of any kind (except foot racing), sky diving, scuba diving and illegal activities; flying except as an ordinary fare paying passenger on a regular public air service or charter plane. Treatment of sexually transmitted diseases. Injuries sustained while committing a crime or felony. Treatment for any form of disability, injury or sickness sustained or contracted due to war or any act of war, terrorist activities, active duty in any armed forces, direct participation in strikes, riot and civil commotion or as a result of natural disaster. Ionizing radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material. Durable and disposable medical supplies (e.g. crutches, syringes). Non-therapeutic dietary supplements (including vitamins), appetite suppressants, anabolic steroids and pharmaceutical products not registered with the Ministry of Health. Indemnity covered by other medical insurance (Ratable Proportion Contribution will be applicable). Pre-existing conditions unless the person covered affected by these conditions has been covered under this Certificate for twelve (12) months or has been continuously covered under a Group Hospital & Surgical Takaful/Insurance immediately prior to the commencement of this Certificate. Outpatient physiotherapy treatment, procurement or use of special braces. Treatment for recuperative purpose as a result of mental fatigue, rest cares or sanitaria care; drug addiction or alcoholism, communicable diseases requiring by law isolation or quarantine in the event of an epidemic, special nursing care. No benefits shall be payable with respect to period of hospital confinement unless the entire confinement and all the specialist hospital services so rendered and performed has been recommended and approved by a Registered Medical Practitioner and in accordance with the diagnosis and treatment of the condition for which the hospital confinement was required.

Effective Date: 24/06/16, Revision 8

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APPENDIX 1 SAMPLE OF PMCARE MEMBERSHIP CARDS / MEDICAL LOGBOOK

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SAMPLE OF PMCARE MEMBERSHIP CARDS/MEDICAL LOG BOOK FOR MEMBER IDENTIFICATION

A. PMCare Membership Card - Smart Card

B. PMCare Membership Card - PVC Card

C. PMCare - Medical Logbook IMPORTANT NOTE This card is to facilitate the hospital to contact PMCare to issue Guarantee Letter for cashless access to the hospital.

Effective Date: 24/06/16, Revision 8

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APPENDIX 2 PMCare Pre-Admission Form

PMCare Pre-Admission Form Important Note : To request a Guarantee Letter, please complete this form prior to admission and email/fax to [email protected]/03 8023 9999. Hospital Name Contact Person

Contact No.

Admission Date

Fax

_______ date _______ month _______ year

Admission Time

______________am/pm

PATIENT INFORMATION Name of Patient PMCare Member ID Name of Employer NRIC No./Birth Certificate No.

Date of Birth

PATIENT MEDICAL CONDITION Blood Pressure Pulse

Presenting symptoms at time of admission and physical finding

Respiratory rate Temperature

Is this the FIRST TIME patient has this/these or similar symptom(s)?

Yes

No

If no, how long has the condition existed?

__________ year(s) __________ month(s) __________ week(s) __________day(s)

When did patient first consult you for this complaint/condition?

_______ date _______ month _______ year

Provisional Diagnosis Etiology of the above diagnosis Yes Cosmetic/Dental care/Refractive error Yes Chronic Illness Yes Influence of Drugs/Alcohol Psychological Disorder/Psychiatric/Sleeping Disorder Self-inflicted injuries/Violation of laws/Strike/Riots Pregnancy Related/Infertility

Please indicate (√) if the present diagnosis is related to

Medical History (Please tick)

Congenital Work STD/HIV/AIDS

No No No

Yes Yes Yes Yes Yes Yes

No No No No No No

Hypertension

Yes

No

Since : ______date______month_____year

Diabetes

Yes

No

Since : ______date______month_____year

Hyperlipidemia

Yes

No

Since : ______date______month_____year

Cardiovascular Disease

Yes

No

Since : ______date______month_____year

Gastrointestinal Disease

Yes

No

Since : ______date______month_____year

Malignancy

Yes

No

Since : ______date______month_____year

Others (Please state, if any) Time of accident

Date of accident

Is this admission due to accident? Yes

No

Injury sustained

If yes, please state: Mechanism of Injury Can this condition be managed under outpatient basis? Yes No If no, please state reason

Admission requires

Hospitalisation

Please state TREATMENT PLAN. e.g. lab test, imaging, and etc

Day Care

On patient’s request

Estimated days of stay

Estimated total cost RM

Signature and stamp of Admitting Physician/Surgeon If Admitting Doctor is a Medical Officer, please state Name and Specialty of Doctor to be referred to

OPS/GL-DA-33, Rev 1,

PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email: [email protected] 33_PMCare Pre-Admission Form_Rev 1

15

APPENDIX 3 Guarantee Letter “GL”

Inpatient “GL”

FORM MM201 (Part I) CRD GL Serial No.

: :

TRANSMISSION Sp/Hosp. Fax No. Other Fax No.

: :

Previous GL Serial No. Date/Time of Issuance Attention To

: : : :

By Hand/Courier/Mail Visit Type Service Type Appointment Date

: : : :

Name of Patient:

GUARANTEE LETTER (“GL”) GL Validity Period: i) To be utilized within fourteen (14) days of issuance of date (inclusive of issuance date). ii) For one (1) Inpatient admission not exceeding ten (10) days. iii) For extension of admission, a new GL must be obtained upon expiry of ten (10) days validity. NRIC No.:

Name of Employee:

Relationship:

Name of Employer:

Program Type:

PMCare Member ID:

Benefit Plan:

1.

This is to acknowledge that PMCare Sdn Bhd undertakes to make payment for Admission expenses incurred for abovenamed patient NOT EXCEEDING the following limits stated in Item No. 2.

2.

The abovenamed patient is entitled to:

A total limit of not more than A daily Room & Board charges inclusive of Meals & Nursing Care of not more than Intensive Care Unit Surgical fees of not more than Anesthetic fees of not more than Hospital Ancillary Services of not more than A daily In–Hospital Physician Visit of not more than Delivery Limit of not more than 3.

Diagnosis (Provisional or Primary)

Important notes: i) Medications are allowed up to a maximum of one (1) month supply if prescribed by the attending doctor. Supply exceeding one (1) month shall be specifically stated above; and ii) For post hospitalization visit, medications supply are allowed up to (DD/MM/YYYY). 4.

5. 6. 7.

Kindly note that: a. Expense entitlement is only for or directly related to medical/surgical condition referred to the Diagnosis as per above Item No. . b. Maternity Benefits coverage does not include expenses incurred for newborn beyond prenatal period. c. PMCare will not pay or be responsible for any expenses in excess of the above entitlement or incurred for non-entitlement as indicated above. The excess amount must be recovered by the hospital from the patient upon their discharge, to be advised in our Discharge Advice. d. Payment of claim is subject to timely submission of complete documents, i.e. within thirty (30) days from date of service or discharge. e. For extension of admission, the hospital must contact PMCare. Kindly fax to our Careline Centre your final itemized bill, with diagnosis and surgical procedures done, so that we can advise you better on the actual coverage, bills and payment. Please attach the completed form MM201 (Part I & II) together with your invoice for payment. Please note that the following non-medical items are under exclusion: Congenital Anomalies; Birth Control & Infertility investigation or treatment; Sexually Transmitted Disease; A.I.D.S; Cosmetic Surgery; Psychiatric Disorder; and Dental Care. For complete listing, please refer to the Working Guidelines.

Yours faithfully,

I, the abovenamed and/or on behalf of my dependent hereby consent to the release of the medical report to PMCare Sdn Bhd/payer for claims processing.

For and on behalf of PMCare Sdn Bhd

…………………………………………… Authorised Signatory

……………………………………………………… Name : NRIC No. :

__________________________________________________________________________________________________ PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email:[email protected] OPS/GL-DA-1, Rev 8 Eff. Date: 01/01/13

1_GL Part 1_Rev 8

18

GL Serial No. : Previous GL No. :

PMCARE SDN BHD (458443-P) FORM MM201 (Part II) Admission/ Appointment Date Discharge Date Visit Type

Patient Name NRIC No. Membership No. Service Type

Time

_____am/pm

Time

_____am/pm

Patient Telephone No. SPECIALIST/CONSULTANT DISCHARGE NOTES Primary Diagnosis

Primary diagnosis (Reason for admission) ICD10 coding, if available Etiology of the above diagnosis

Presenting symptoms at time of admission When was the date patient sought your consultation for this condition? To your knowledge, was the patient previously treated for this condition? In your professional opinion, when did the condition first develop?

_____________ day _____________ month _____________ year No

Yes

When? _____________ day _____________ month _____________ year

Name/Address & contact number : ___________________________________________________________________________________________

_____________ day _____________ month _____________ year

Any possibility of relapse?

No

Yes

Motor vehicle accident related

No

Date of accident

_________day _________month _________ year

Time of accident

_____________ am/pm

Yes

Please indicate (√) if the illness/injury or treatment is/are Chronic

No

Yes

Cosmetic

No

Yes

Pregnancy related

No

Yes

Fertility related

No

Yes

Work related

No

Yes

Congenital

No

Yes

Psychological related

No Yes Secondary Diagnosis

Diagnosis other than primary

Has patient suffered from/Is patient suffering any illnesses stated as follows:

Hypertension

No

Yes

Since?

Cardiovascular Disease

No

Yes

Since?

Gastrointestinal Disease

No

Yes

Since?

Malignancy of any kind

No

Yes

Since?

Diabetes

No

Yes

Since?

Others

OPS/GL-DA-1, Rev 8 Eff. Date: 01/01/13

No

Yes

Page 1 of 2

Since?

_____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________

day _____________ year day _____________ year day _____________ year day _____________ year day _____________ year

month month month month month

If yes, please specify _______________________________________ _____________ day _____________ month _____________ year 1_GL Part 2_Rev 8

19

PMCARE SDN BHD (458443-P) FORM MM201 (Part II)

GL Serial No. : Previous GL No. :

Treatment & Investigation Blood Test

Please indicate (√) nature of treatment and Investigation

Dietary Counseling

Medical

Operation

Physiotherapy

X-ray

Others, Please specify : _________________________________________________________________

Medication dispensed

Type of Operation/Procedure/ Investigation

Date Performed

Performed by

Please state procedures, investigation and operations performed

Referred Doctors & Specialty

Name of Doctor

Specialty

Name of Doctor

Specialty

Name of Doctor

Specialty Follow up Treatment

Follow-up necessary?

No

Yes

Please indicate (√) if patient needs to be/was crossed referred?

No

Yes

If Yes, to which specialist? (Please state reason)

Attending Doctor In the case of DEATH, please advise

Date

___________day__________month ___________year

Time

Cause of Death

____________am/pm To the best of my knowledge, I hereby declare that all the information given above is true and accurate.

______________________________

______________________________

Attending Doctor’s Stamp

Signature of Attending Doctor

______________________________

Date

PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email:[email protected]

OPS/GL-DA-1, Rev 8 Eff. Date: 01/01/13

Page 2 of 2

1_GL Part 2_Rev 8

20

Outpatient “GL”

FORM MM201 (Part 1)

CRD GL Serial No. Previous GL Serial No. Date / Time of Issuance Attention To

TRANSMISSION : : : : : :

Sp/Hosp. Fax No. Other Fax No. By Hand/Courier/Mail Visit Type Service Type Appointment Date

: : : : : :

GUARANTEE LETTER (“GL”) GL Validity Period: i) To be utilized within fourteen (14) days of issuance of date (inclusive of issuance date). ii) For one (1) Outpatient visit only. Name of Patient:

NRIC No.:

Name of Employee:

Relationship:

Name of Employer:

Program Type:

PMCare Member ID:

Benefit Plan:

8.

This is to acknowledge that PMCare Sdn Bhd undertakes to make payment for Outpatient visit expenses incurred for abovenamed patient NOT EXCEEDING the following limits stated in Item No. 2.

9.

The abovenamed patient is entitled to (RM) _____ Initial Limit

10. Diagnosis (Provisional or Primary)

11. Kindly note that: a. Expense entitlement is only for or directly related to medical / surgical condition referred to the Diagnosis as per above Item No. 3. b. PMCare will not pay or be responsible for any expenses in excess of the above entitlement or incurred for non-entitlement as indicated above. The excess amount must be recovered by the hospital from the patient upon their discharge. c. Payment of claim is subject to timely submission of complete documents, i.e. within 30 days from date of service or discharge. d. Maternity Benefits coverage does not include expenses incurred for newborn beyond prenatal period. 12. Please attach the completed form MM201 (Part I & II) together with your invoice for payment. 13. Please note that the following non-medical items are not covered: Congenital Anomalies, Birth Control & Infertility investigation or treatment; Sexually Transmitted Disease; A.I.D.S; Cosmetic Surgery; Psychiatry Disorder; and Dental Care. For complete listing, please refer to the Working Guidelines.

Yours faithfully,

I, the abovenamed and/or on behalf of my dependent hereby consent to the release of the medical report/information to PMCare Sdn Bhd and/or my employer for claims processing.

For and on behalf of PMCare Sdn Bhd. …………………………………………… Authorised Signatory

……………………………………………………… Name : NRIC No. :

___________________________________________________________________________________________________ PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email: [email protected] OPS/GL-DA-1a, Rev 9, Eff Date: 08/07/2015

Page 1 of 1

1a_GL Part 1_Rev 9

22

FORM MM201 (Part II) GL Serial No. GL Issued To

: :

Visit Type Service Type Appointment Date

Name of Patient:

NRIC:

Name of Employee:

Benefit Plan:

: : :

THE FOLLOWING ITEMS ARE NOT COVERED UNDER THE PROGRAM Treatment by acupuncturist, homeopath and traditional Expenses incurred during hospitalization which are of a medicine practitioner personal nature, e.g food, telephone, extra bed. Contraceptive treatment such as taking family planning Treatment of cosmetic nature pills, IUD, sterilization Infertility treatment Abortion and venereal disease treatment Treatment arising from intentional or self-inflicted injuries Aids for correction of eyesight and hearing REASON FOR REFERRAL (Based on Referral/Previous Notes)

SPECIALIST CONSULTANT OR ADMISSION NOTES Provisional Diagnosis

Final Diagnosis

ICD10 coding, if available Since when condition deemed to have started

Major Procedure(s) - if any

Please indicate √ if this illness or treatment is/are

Pregnancy-related Infertility-related Congenital

Follow-up necessary?

Please indicate √ if patient needs to be/was crossed

Chronic Cosmetic Work-related

Psychological MVA-related

No

Yes No

referred?

Yes

If Yes, to which specialist? (Please state reasons)

N/A = Applicable

FU = Follow Up

FV = First Visit

________________________ Signature of Attending Specialist

____________________ Medical Facility Stamp

Note: Once stable, please refer the patient back to the referring doctor or his/her regular GP with appropriate advise. PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 Email: [email protected] OPS/GL-DA-1a, Rev 9, Eff Date: 08/07/2015

Page 2 of 2

1a_GL Part 2_Rev 9.doc

23

APPENDIX 4 REQUEST FOR EXTENDED ADMISSION GL FORM

PRIORITY REQUEST FOR EXTENDED ADMISSION GL Name of Patient / Member

We have assessed the abovenamed patient / member who has been admitted on with GL Number

for

Working diagnosis and previous procedure(s), if any:

And based on the following: Current complication(s) and / or procedure(s) to be done:

Strongly recommend the admission / stay be further extended. Thank you Yours faithfully

Signature of Attending Doctor Date:

Doctor and Hospital Stamp

For PMCare use only

Time

Personnel

Received Approve/Reject Reason GL No. (if issued) Hospital advised PMCare Record OPS/GL-DA-13, Rev 0, Eff Date: 02/07/07

Request for Extended Admission GL_Rev 0

25

APPENDIX 5 GUARANTEE LETTER REQUEST DENIED FORM

GUARANTEE LETTER REQUEST DENIED FAX TRANSMISSION To Attention Contact No From Attending Officer Date

: : : : : :

WHOM IT MAY CONCERN Fax No.

:

Phone No.

:

Phone No.

: :

PMCare Sdn Bhd – Operations Dept. Fax No.

603-8026 6888 603-8023 9999

Dear Sir/ Madam, Please be advised that PMCare Sdn Bhd is not able to issue a Guarantee Letter for this Member: A. Name : B. Membership ID : C. Company : D. Plan : The request for the Guarantee Letter has been denied due to the following reason(s): 1. Member / Dependant name is not registered or terminated. 2. Exceeded limit for outpatient / inpatient coverage. 3. Diagnosis / treatment not covered (e.g.: Congenital Anomalies, Infertility etc.). 4. Incomplete document: a. No referral letter from panel clinic / BPR (for TNB only). b. No appointment card/appointment letter (for CIMB Bank only). c. No admission form. 5. Incomplete information (e.g.: no membership ID, fax/contact no. / clinic rubber stamp/ diagnosis etc.). 6. Non emergency case. 7. Patient to seek treatment at GP panel after 3 visits, new referral letter to be issued by panel GP only if necessary. 8. No previous record. 9. Plan coverage at Government Hospital (GH) only. 10. Outpatient treatment falls under Pay & Claim basis. 11. GL requested too early prior to appointment date. Please resubmit on: _______________________ 12. GL cancelled. GL Serial No.: ______________________ 13. 13. Others.

Remarks: For further information, kindly contact our Member Support Executives at PMCare Careline number 03-8026 7799. Thank you. Yours faithfully, For and on behalf of PMCare Sdn Bhd

……………………………

General Manager, Operations PMCare Sdn Bhd (458443-P) No 1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. Tel: 603-8026 6888 Fax: 603-8023 9999 OPS/GL-DA-22, Rev 0, Eff Date: 12/10/11 GL Request Denied Rev 0 www.pmcare4u.com.my

27

APPENDIX 6 CONSENT FORM

CONSENT FORM Specialist consultation

NOTIFICATION FOR PMCare Premier Card

(Please

one)

Others

Admission

Patient’s details Name of patient Membership no. Name of employee Membership no. I, the above named or behalf of my dependent are hereby consent to release the medical report and related information to PMCare Sdn Bhd and/or my employer for reimbursement and utilization report.

(Please sign) Name: Date:

(Please

SPECIALIST CONSULTATION OR ADMISSION NOTES

one)

Specialist consultation

Date of consultation/ admission

Admission

Working diagnosis

Since when condition deemed to have started

Procedure(s) if any

Please indicate illness

Please indicate

Pregnancy related

Self inflicted

Chronic disease / disorder

Infertility related

Cosmetic

Psychiatric disorder

Congenital

Work related

Non-specific (investigation)

if patient needs to be cross referred

Yes

No

If Yes, please give reasons

Signature of attending specialist:

Date:

Name of attending specialist:

Medical provider rubber stamp

Remarks (For PMCare use only)

NOTES: 1. A PHOTOCOPY OR FAX COPY OF THIS CONSENT FORM SHALL BE VALID AS ORIGINAL. 2. KINDLY SUBMIT THIS CONSENT FORM TOGETHER WITH THE ITEMISED BILLING TO: PMCARE SDN BHD CLAIMS DEPARTMENT No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. Tel: 03-8026 6888 Fax: 03-8023 9999 www.pmcare4u.com.my

MD/MP-2, Rev 7, Eff Date: 01/04/16

2_Consent Form _Rev 7

29

APPENDIX 7 DISCHARGE ADVICE (“DA”)

30

Discharge Advice

Form MM-D To Attention Fax/Phone No. From Attending Officer Date

: : : : : :

HOSPITAL Billing Department 603-4255 2709 PMCARE SDN BHD Mr. Ahmad Musa 04/10/2017 3:31 PM

Our Reference GL No. Discharge Bill No. Patient Name Patient Member ID Company/Plan Diagnosis

: : : : : :

142003120177100 821543

Discharged Advice No. : DA / 4172 Total Bill Amount : RM 8588.94

M-M-7086872-S1 TELEKOM MALAYSIA BERHAD

Plan : T4B Plan name: GP,SP,HP(2BR_50K)_D_

No of pages (including this page):1 Phone Fax

: :

603-8026 6855/54 603-8023 9999

Dear Sir/Madam, With reference to your discharge bill no. 821543 dated 4-Oct-17, kindly be advised on the following: No excess was incurred. Please facilitate discharge of patient. X

The patient has incurred excess. Please collect the total excess amount RM 48.24 from the patient.

Details of Excess: Room & Board Intensive Care Unit Surgery/Surgeon Fee Anesthetic Fee Hospital Ancillary Services Physician Visit/Ward Review Government Tax Others T Total Excess

(RM) 42.00 + 3.84 + 2.40 RM 48.24

Important: 1. Please be advised that PMCare Sdn Bhd shall not make any payment or be responsible for any expenses in excess of the patient’s entitlement for or directly related to medical/surgical condition referred to the Diagnosis as per GL part I, Item No. 3, in the GL No. 142003120177100. 2. Any excess amount must be recovered by the hospital from the patient upon confirmation of the Discharge Advice (“DA”). 3. Hospital is required to request for a fresh confirmation in the event change is made to the bill after PMCare’s confirmation as payment is strictly based on the DA confirmed. However, PMCare reserved the right to revise if non covered items/treatment/diagnosis is discovered from the final bill. 4. If there is no revision of computation of DA within seven (7) days from today, this DA is confirmed as final. Thank you for your excellent services to our members. Yours faithfully For and on behalf of PMCARE SDN BHD …………………………… Authorized Signatory PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 03-8026 7799 Careline Centre Fax: 03-8023 9999 CD/SP-HP-9, Rev 0, Eff. Date: 14/07/15

9_DA Form_Rev 0

31

APPENDIX 8 CONFIRMATION OF RECEIPT OF MEDICAL CLAIMS INVOICES

________________________________________________________________________________ Date: 24-Dec-12 HOSPITAL SIHAT 135 Jalan Sihat Sentiasa 51200 Kuala Lumpur Fax No: 03-40465484 Attention : Billing / Credit Control Department Dear Sirs, CONFIRMATION OF RECEIPT OF MEDICAL CLAIMS INVOICES

E L

We wish to confirm that we have received the following claims submission from your hospital on 05 May 2004. 1. Claims Summary dated 2. Reference No. 3. The total number of claims received was For details of status of your claims submission,

: NIL : NIL : 19 please refer to attachment.

P M

If your submission had been classified as “Incomplete” (IC), kindly ensure the following are completed and resubmitted to us within 7 days of this letter: i) GL Part 1, ii) GL Part 2 ( duly completed with description of diagnosis); and iii) Doctor’s signature and stamp on GL Part 2. iv) Details billing.

A S

We take this opportunity to remind you to ensure that your claims are complete consisting of original invoices, GL Part 1, GL Part 2 duly completed with description of diagnosis, details billing, Doctor’s signature, Providers stamp and submit to us within 30 days from the date of service. (Refer to PMCare Working Guidelines for Hospital and Specialist Clinics) Kindly acknowledge receipt of this letter and return by fax to 03-8023 9097 immediately. “WE CARE” Thank you. For and on behalf of PMCARE SDN BHD

I hereby acknowledge receipt of this letter.

This is a computer generated. No signature is required. ……………………………………………. Signed by : Date :

_______________________________________________________________________________________________ PMCARE SDN BHD (458443-P) No. 1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. Tel 03-8026 6888 Fax: 03-8023 9097

33 23

PMCARE SDN BHD SP And HP Claims Registration Details

S

E E L L P P M M A AS

34

APPENDIX 9 DIRECTORY FOR MEDICAL DEPARTMENT STAFF

DIRECTORY FOR MEDICAL DEPARTMENT STAFF No. 1. 2. 3.

Name Dr. Mohd Helmi Ismail Medical Director Dr. Jasman Haris Assistant Medical Director Rozita Mohamed Noor Provider Network Manager

Telephone

E-Mail

03-8026 6861

[email protected]

03-8026 6863

[email protected]

03-8026 6876

[email protected]

03-8026 6874

[email protected]

03-8026 6873

[email protected]

03-8026 6875

[email protected]

03-8026 6871

[email protected]

03-8026 6871

[email protected]

03-8026 6874

[email protected]

03-8026 6879

[email protected]

03-8026 6879

[email protected]

03-8026 6873

[email protected]

03-8026 6877

[email protected]

03-8026 6869

[email protected]

03-8026 6877

[email protected]

03-8026 6867

[email protected]

03-8026 6877

[email protected]

03-8026 6866

[email protected]

03-8026 6867

[email protected]

03-8026 6869

[email protected]

03-8026 6878

[email protected]

03-8026 6872

[email protected]

03-8026 6878

[email protected]

03-8026 7655

[email protected]

03-8026 6865

[email protected]

03-8026 7655

[email protected]

03-8026 6873

[email protected]

PROVIDER NETWORK – HOSPITAL & SPECIALIST UNIT 4. 5. 6. 7. 8. 9. 10. 11. 12.

Azni Abu Bakar Provider Network Assistant Manager Faezah Ibrahim Provider Network Senior Executive Noor Suhaida Shariff Provider Network Executive Mohd Hudzaifah Zulkafli Provider Network Executive Norwatilah Shood Provider Network Junior Executive Noor Faliza Ismail Provider Network Senior Clerk Nurshafika Othman Provider Network Junior Executive Ummi Sakina Mohd Provider Network Junior Executive Naieemah Ibrahim Provider Network Junior Executive

PROVIDER NETWORK – DENTAL CLINIC UNIT 13.

Fatin Athirah Zakaria Provider Network Junior Executive

PROVIDER NETWORK – GP CLINIC UNIT 14. 15. 16. 17. 18. 19. 20.

Azlina Misro Provider Network Senior Executive Josniha Joehari Provider Network Senior Executive Ahmad Hazim Hassim Provider Network Junior Executive Rosilawati Shafee Provider Network Executive Sarenawaty Md Reduan Provider Network Junior Executive Mazura Abdul Hamid Provider Network Junior Executive Masykurah Muhamad Abdullah Provider Network Junior Executive

MEDICAL MANAGEMENT UNIT 21. 22. 23. 24. 25. 26. 27.

S. Mahandrran Medical Management Senior Manager Zaini Che Ghani Medical Management Senior Executive Muhammad Haziq Haris Medical Management Junior Executive Khalidah Kailan Medical Management Senior Executive Syazana Abdul Azis Medical Management Executive Rohana Abdul Wahab Medical Management Executive Nur Syahira Zahirudin Provider Network Junior Executive

36

THANK YOU FOR YOUR EXCELLENT SERVICE