pmcare sdn bhd guidelines for...pmcare sdn bhd working guidelines for pmcare panel of hospital &...

PMCARE SDN BHD

WORKING GUIDELINES FOR HOSPITALS AND

SPECIALIST CLINICS

TABLE OF CONTENT

ITEM PAGE

CHAPTER 1: 1

1.1 Introduction 1

1.2 Hospital & Specialist Clinic Address 1 1.3 Provider Code 1

1.4 Identification of PMCare Member 1 1.5 Verification of PMCare Member 1

1.6 Medical Record 1

1.7 Exclusions 2 1.8 Charges 2

1.9 Claims Submission 2 1.10 Submission Deadline 2

1.11 Deductions From Amount Claimed 2

1.12 Appellant 2 1.13 Temporary Suspension of Service 2

1.14 Termination 2 1.15 Communication 3

CHAPTER 2: CONSULTATION AND ADMISSION PROCEDURES 4

2.0 Provision of Services 5

2.1 For PMCare Members 5

2.2 For PMCare Premier Card Holder 5

CHAPTER 3: BILLING AND DISCHARGE PROCEDURES 6

3.0 Guides on Discharge Procedures 7 3.1 For PMCare Members 7

3.2 For PMCare Premier Card Holder 7

CHAPTER 4: CLAIMS SUBMISSION PROCEDURES 8

4.0 Claims Submission Procedures 9

4.1 Submission Deadline And Requirements 9 4.2 Documents and Information Required for Claims Submission for Reimbursement 9

4.3 PMCare Premier Card Holder 9

CHAPTER 5: EXCLUSION LIST 10

5.0 Exclusion List 11

APPENDIXES:

APPENDIX 1: Sample of PMCare Membership Cards/Medical Logbook 12 & 13

APPENDIX 2: PMCare Pre-Admission 14 & 15

APPENDIX 3: Guarantee Letter (“GL”) 16 - 23

APPENDIX 4: Request for Extended Admission GL Form 24 & 25

APPENDIX 5: Guarantee Letter Request Denied 26 & 27

APPENDIX 6: Consent Form 28 & 29

APPENDIX 7: Discharge Advice (“DA”) 30 & 31 APPENDIX 8: Confirmation of Receipt of Medical Claims Invoices 32 - 34

APPENDIX 9: Directory for Medical Department Staff 35 & 36

PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF

HOSPITAL & SPECIALIST CLINICS

CHAPTER 1

Effective Date: 24/06/2016, Revision 8 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



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.



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.

CONSULTATION AND ADMISSION PROCEDURES

2.0 PROVISION OF SERVICES

2.1 FOR PMCARE MEMBERS

2.1.1 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. 2.1.2 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).

2.1.3 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. 2.1.4 Patient or guardian shall sign on our GL-Part 1 for consent to release medical information

to PMCare.

2.1.5 Patient receives treatment and medication. 2.1.6 The hospital shall then bill PMCare. Please refer to the Claim Submission Procedures (Page

8) to ensure the required documents are submitted for payment. 2.1.7 Please refer to Page 12 for various samples of PMCare membership cards or logbooks.

Important Notes:

2.1.8 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.

2.1.9 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.

2.2 FOR PMCARE PREMIER CARD

2.2.1 Member must produce a valid PMCare Premier Card to the registration personnel.

2.2.2 Member must sign a Consent Form (Refer Appendix 6) to release medical information to PMCare.

2.2.3 This card can be used for both outpatient and inpatient treatment. 2.2.4 Access to the hospitals shall be on direct access; referral letters are not required.

2.2.5 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).

2.2.6 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

5

BILLING AND DISCHARGE PROCEDURES


HOSPITAL & SPECIALIST CLINIC

CHAPTER 3


3.0 GUIDES ON DISCHARGE PROCEDURES

3.1 FOR PMCARE MEMBERS

3.1.1 Hospital must fax the following documents to PMCare before patient is discharged:

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)

3.2 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.

CLAIMS SUBMISSION PROCEDURES

9

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 Original & Detail Invoice

FOR ALL CLAIMS

FOR ALL CLAIMS

2 Guarantee Letter Part I

3 Guarantee Letter Part II (Doctor’s Brief Note)

4 Drugs/Medicine/Pharmacy details

5 Descriptions of procedure done by

each doctor

6 Type of Surgery done by each

doctor

7 Medical supplies / Disposables

8 Operation Theatre Supplies

9 Descriptions of package (e.g. PTCA,

Maternity etc)

10 Descriptions of Implant / Medical

Devices

11 Descriptions of Laboratory Charges

12 Descriptions of Special Diagnostic (e.g. X-ray, Ct Scan etc)

13 Descriptions of Injections / Drips

14 Descriptions of Miscellaneous Charges

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


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 AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS related complex), and all illnesses or

diseases in the presence of the Human Immune-deficiency Virus (HIV).

5.2 Non-medical services provided by a hospital such as radio, television, telephone, fax or similar

facilities.

5.3 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.

5.4 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. 5.5 Disabilities of a newborn child contracted prior to or during birth or in the first 14 days thereafter. 5.6 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.

5.7 Congenital anomalies diagnosed or identified during or after birth or even at later age. 5.8 Birth control, sexual dysfunction (i.e. Viagra), infertility investigation and treatment. 5.9 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). 5.10 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. 5.11 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.

5.12 Treatment of sexually transmitted diseases. 5.13 Injuries sustained while committing a crime or felony. 5.14 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.

5.15 Ionizing radiation or contamination by radioactivity from any nuclear fuel or nuclear waste from process of nuclear fission or from any nuclear weapons material.

5.16 Durable and disposable medical supplies (e.g. crutches, syringes). 5.17 Non-therapeutic dietary supplements (including vitamins), appetite suppressants, anabolic steroids

and pharmaceutical products not registered with the Ministry of Health. 5.18 Indemnity covered by other medical insurance (Ratable Proportion Contribution will be applicable). 5.19 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. 5.20 Outpatient physiotherapy treatment, procurement or use of special braces. 5.21 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. 5.22 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.

12

APPENDIX 1

SAMPLE OF PMCARE MEMBERSHIP CARDS / MEDICAL LOGBOOK


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 Letterfor cashless access to the hospital.

APPENDIX 2

PMCare Pre-Admission Form

15

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. Fax

Admission Date _______ 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

Presenting symptoms at time of admission and physical finding

Blood Pressure

Pulse

Respiratory rate

Temperature

Is this the FIRST TIME patient has this/these or similar symptom(s)? If no, how long has the condition existed? When did patient first consult you for this complaint/condition?

Yes No

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

Provisional Diagnosis

Etiology of the above diagnosis

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

Cosmetic/Dental care/Refractive error Yes No Congenital Yes No

Chronic Illness Yes No Work Yes No

Influence of Drugs/Alcohol Yes No STD/HIV/AIDS Yes No

Psychological Disorder/Psychiatric/Sleeping Disorder Yes No

Self-inflicted injuries/Violation of laws/Strike/Riots Yes No

Pregnancy Related/Infertility Yes No

Medical History (Please tick) Others (Please state, if any)

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

Is this admission due to accident? Yes No

If yes, please state:

Time of accident Date of accident

Injury sustained

Mechanism of Injury

Can this condition be managed under

outpatient basis? Yes No

If no, please state reason

Admission requires Hospitalisation Day Care On patient’s request Estimated days of stay

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

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

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-33, Rev 1, 33_PMCare Pre-Admission Form_Rev 1

mailto:[email protected]

APPENDIX 3

Guarantee Letter “GL”

Inpatient “GL”

18

FORM MM201 (Part I) TRANSMISSION

CRD : Sp/Hosp. Fax No. :

GL Serial No. : Other Fax No. :

Previous GL Serial No. : By Hand/Courier/Mail :

Date/Time of Issuance : Visit Type : Attention : Service Type : To : 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) 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.

Name of Patient: 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. 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. 5. 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. 6. Please attach the completed form MM201 (Part I & II) together with your invoice for payment. 7. 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.

__________________________________________________________________________________________________ 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

Yours faithfully, For and on behalf of PMCare Sdn Bhd

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

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.

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


FORM MM201 (Part II)

Patient Name Admission/

Appointment Date Time _____am/pm

NRIC No. Discharge Date Time _____am/pm

Membership No. Visit Type

Service Type 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? _____________ day _____________ month _____________ year

To your knowledge, was the patient previously treated for this condition?

No Yes When? _____________ day _____________ month _____________ year

Name/Address & contact number : -

___________________________________________________________________________________________

In your professional opinion, when did the condition first develop? _____________ day _____________ month _____________ year

Any possibility of relapse? No Yes

Please indicate (√) if the

illness/injury or treatment is/are

Motor vehicle accident related

No Yes

Date of accident

_________day _________month

_________ year

Time of accident _____________ am/pm

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? _____________ day _____________ month _____________ year

Cardiovascular Disease No Yes Since? _____________ day _____________ month _____________ year

Gastrointestinal Disease

No Yes Since? _____________ day _____________ month _____________ year

Malignancy of any kind No Yes Since? _____________ day _____________ month _____________ year

Diabetes No Yes Since? _____________ day _____________ month _____________ year

Others

No Yes Since?

If yes, please specify

_______________________________________ _____________ day _____________ month

_____________ year

OPS/GL-DA-1, Rev 8 Eff. Date: 01/01/13 Page 1 of 2 1_GL Part 2_Rev 8

GL Serial No. :

Previous GL No. :

19

OPS/GL-DA-1, Rev 8 Eff. Date: 01/01/13 Page 2 of 2 1_GL Part 2_Rev 8

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

Treatment & Investigation

Please indicate (√) nature of treatment and Investigation

Blood Test Dietary Counseling Medical Operation

Physiotherapy X-ray

Others, Please specify : _________________________________________________________________

Medication dispensed

Please state procedures, investigation and operations

performed

Type of Operation/Procedure/ Investigation

Date Performed Performed by

Referred Doctors & Specialty

Name of Doctor

Specialty

Name of Doctor

Specialty

Name of Doctor

Specialty

Follow up Treatment

Follow-up necessary?

No Yes

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

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

No Yes

Attending Doctor

In the case of DEATH, please

advise

Date ___________day__________month ___________year

Cause of Death

Time ____________am/pm

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


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]

______________________________

Signature of Attending Doctor

______________________________

Attending Doctor’s Stamp

______________________________

Date

GL Serial No. : Previous GL No. :

20

Outpatient “GL”

FORM MM201 (Part 1) TRANSMISSION

CRD : Sp/Hosp. Fax No. :

GL Serial No. : Other Fax No. :

Previous GL Serial No. : By Hand/Courier/Mail :

Date / Time of Issuance : Visit Type : Attention : Service Type : To : 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. ……………………………………………………… …………………………………………… Name : Authorised Signatory 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. : Visit Type : GL Issued To : 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 medicine practitioner

Expenses incurred during hospitalization which are of a personal nature, e.g food, telephone, extra bed.

Contraceptive treatment such as taking family planning pills, IUD, sterilization

Treatment of cosmetic nature

Infertility treatment Abortion and venereal disease treatment

Aids for correction of eyesight and hearing Treatment arising from intentional or self-inflicted injuries

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 √ Pregnancy-related Chronic Psychological

if this illness Infertility-related Cosmetic MVA-related or treatment is/are Congenital Work-related Follow-up necessary? No Yes

Please indicate √ if patient needs to be/was crossed referred? No 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.


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 Doctor and Hospital Stamp Date:

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

For PMCare use only

25

APPENDIX 5

GUARANTEE LETTER REQUEST DENIED FORM

OPS/GL-DA-22, Rev 0, Eff Date: 12/10/11 GL Request Denied Rev 0

GUARANTEE LETTER REQUEST DENIED

FAX TRANSMISSION

To : Attention : WHOM IT MAY CONCERN

Contact No : Fax No. : Phone No. : From : PMCare Sdn Bhd – Operations Dept.

Attending Officer : Phone No. : 603-8026 6888

Date : Fax No. : 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 www.pmcare4u.com.my

27

APPENDIX 6

CONSENT FORM

29

CONSENT FORM

NOTIFICATION FOR

(Please one)

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)

SPECIALIST CONSULTATION OR ADMISSION NOTES

Date of consultation/admission

Signature of attending specialist:

PMCARE SDN BHDCLAIMS DEPARTMENT

No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. Tel: 03-8026 6888 Fax: 03-8023 9999www.pmcare4u.com.my

Remarks (For PMCare use only)

Others

Patient’s details

(Please one)

Working diagnosis

Since when condition deemed to have started

Procedure(s) if any

Please indicate illness

Pregnancy related

Infertility related

Congenital

Self inflicted

Cosmetic

Work related

Chronic disease / disorder

Non-specific (investigation)

Psychiatric disorder

Please indicate if patient needs to be cross referred Yes No

If Yes, please give reasons

Name of patient

Membership no.

Name of employee

Membership no.

Name:Date:

Name of attending specialist:

Date: Medical provider rubber stamp

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:

Specialist consultation

Admission

PMCare Premier Card

Specialist consultation

Admission

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

30

APPENDIX 7

DISCHARGE ADVICE (“DA”)

31

Form MM-D Discharge Advice To : HOSPITAL

Attention : Billing Department

Fax/Phone No. : 603-4255 2709 No of pages (including this page):1

From : PMCARE SDN BHD

Attending Officer : Mr. Ahmad Musa Phone : 603-8026 6855/54

Date : 04/10/2017 3:31 PM Fax : 603-8023 9999

Our Reference

GL No. : 142003120177100 Discharged Advice No. : DA / 4172

Discharge Bill No. : 821543 Total Bill Amount : RM 8588.94

Patient Name :

Patient Member ID : M-M-7086872-S1 Plan : T4B

Company/Plan : TELEKOM MALAYSIA BERHAD Plan name: GP,SP,HP(2BR_50K)_D_

Diagnosis :

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: (RM)

Room & Board -

Intensive Care Unit -

Surgery/Surgeon Fee -

Anesthetic Fee -

Hospital Ancillary Services -

Physician Visit/Ward Review -

Government Tax -

Others 42.00 + 3.84 + 2.40

T Total Excess 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


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

APPENDIX 8

CONFIRMATION OF RECEIPT OF MEDICAL CLAIMS INVOICES

S A M P L E

33 23

________________________________________________________________________________

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

We wish to confirm that we have received the following claims submission from your hospital on

05 May 2004.

1. Claims Summary dated : NIL

2. Reference No. : NIL 3. The total number of claims received was : 19

For details of status of your claims submission, please refer to attachment.

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.

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 I hereby acknowledge receipt of this letter.

PMCARE SDN BHD

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

S A M P L E

S A M P L E

34

PMCARE SDN BHD SP And HP Claims Registration Details

APPENDIX 9

DIRECTORY FOR MEDICAL DEPARTMENT STAFF

36

DIRECTORY FOR MEDICAL DEPARTMENT STAFF

No. Name Telephone E-Mail

1. Dr. Mohd Helmi Ismail Medical Director

03-8026 6861 [email protected]

2. Dr. Jasman Haris Assistant Medical Director


3. Rozita Mohamed Noor Provider Network Manager


PROVIDER NETWORK – HOSPITAL & SPECIALIST UNIT

4. Azni Abu Bakar Provider Network Assistant Manager


5. Faezah Ibrahim Provider Network Senior Executive


6. Noor Suhaida Shariff Provider Network Executive


7. Mohd Hudzaifah Zulkafli Provider Network Executive


8. Norwatilah Shood Provider Network Junior Executive


9. Noor Faliza Ismail Provider Network Senior Clerk


10. Nurshafika Othman Provider Network Junior Executive


11. Ummi Sakina Mohd Provider Network Junior Executive


12. 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. Azlina Misro Provider Network Senior Executive


15. Josniha Joehari Provider Network Senior Executive


16. Ahmad Hazim Hassim Provider Network Junior Executive


17. Rosilawati Shafee Provider Network Executive


18. Sarenawaty Md Reduan Provider Network Junior Executive


19. Mazura Abdul Hamid Provider Network Junior Executive


20. Masykurah Muhamad Abdullah Provider Network Junior Executive


MEDICAL MANAGEMENT UNIT

21. S. Mahandrran Medical Management Senior Manager


22. Zaini Che Ghani Medical Management Senior Executive


23. Muhammad Haziq Haris Medical Management Junior Executive


24. Khalidah Kailan Medical Management Senior Executive


25. Syazana Abdul Azis Medical Management Executive


26. Rohana Abdul Wahab Medical Management Executive


27. Nur Syahira Zahirudin Provider Network Junior Executive 03-8026 6873 [email protected]

















THANK YOU FOR YOUR

EXCELLENT SERVICE