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Intellicare
 

Intellicare

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    Intellicare Intellicare Presentation Transcript

    • Established in 1995100% wholly-Filipino owned50M pesos paid up capitalization473,000 membership baseWidest accreditation network Over 650 major hospitals and first-class clinics Approximately 10,000 reputable physicians and specialists More than 400 dentists nationwideStrong manpower complement and infrastructure 24/7 Customer Service assistance Highly-personalized service of Patient Relations Officers during in-patient cases Satellite offices in key cities and provinces 3 mobile clinics and 8 full service clinicsAbove 90% client retention rate
    • • ELIGIBLE DEPENDENTS• Enrollment must follow this order (Hierarchy Rule)• For Single Principal Members 1. Mother or father – not over 65 years old 2. Siblings – Not over 21 years old – Unmarried – Unemployed *For Single Parents, Biological Children may be enrolled first before the parents
    • • For Married Principal Members 1. Legal spouse – not over 65 years old 2. Children – Biological / Legitimate / Legally adopted – 30 days – 21 years old – Unmarried – Unemployed
    • • Enrollment period – 30 days window Dependents – 30 days from effectivity date of coverage No additional dependents except for: Newly born baby – 30 days from date of birth Spouse of newly wed employees – 30 days from date of marriage Dependent of a new employee – 30 days from effectivity date of Principal member
    • OP Availment ACCREDITED FACILITIES EXCEPT HEALTHWAY IP Availment OPEN DOOR POLICY Room and Board MBL Per illness/ member/ year REGULAR PRIVATE 120,000 Pre-Existing Condition* CoverageExisting Principals New Principals Existing Dependents New Dependents MBL MBL MBL 15,000 Philhealth Required System Uses Electronic Eligibility Verification System (through Medilink Network Inc.’s POS Terminals)
    • Features and Benefits Determines member’s status and extent ofbenefit prior to service availment Generates an electronic approved or declined response uponswiping magnetized card Faster transactions in terms of verification of status ofmembership Efficient tracking of fraud Dynamic data is stored in our database not in the card(no need to reprint new cards e.g. during renewals, changes inplan) POS Terminals are accessible 24/7 (major Intellicare providershave POS terminals in place and are ideally located in –Admitting, Billing, Credit and Collection, Industrialclinics, Information, Emergency Room of the hospitals). Refer to your directory for locations of POS terminals
    • For Active and Eligible Members –POS Terminal will instantly generate a 2-page LOE(Letter of Eligibility) depending on type of claime.g. OP-Outpatient, IP-Inpatient,ER-Emergency For Inactive and Ineligible Members – POS Terminal will display “Call IntelliCare” When POS terminal is down – (e.g brownouts) Hospital staff will issue a Manual LOE *For accredited clinics/hospitals without POS terminals – proceed to the IntelliCare Hospital Coordinator or call IntelliCare Customer Service for assistance
    • Name of Provider Name of Provider Name of Member Name of Member Date & Time of Date & Time of Availment AvailmentLine 1 Payor, LOE No. Line 1 Payor, LOE No.Line 2 Policy Number Line 2 Policy NumberLine 3 Member’s Name Line 3 Member’s NameLine 4 Age, Plan Effectivity, Coverage Line 4 Age, Plan Effectivity, CoverageLine 5 Benefits Line 5Line 6 PHIC Required or Not Line 6 BenefitsLine 7 PEC Coverage or Line 7 Room and Board Non Coverage Line 8 PhilhealthLine 8 Exclusions, if any Line 9 PEC Coverage orLine 9 Instructions to Providers Non Coverage Re: Procedures
    • Preventive Care Annual Physical exam Routine ImmunizationOutpatient care Out Patient Care GuidelinesInpatient care In Patient Care GuidelinesEmergency care Emergency Care Guidelines Reimbursement GuidelinesAdditional Benefits Dental Care Dental Care Guidelines Financial assistance
    • For Principals & Dependents• ANNUAL PHYSICAL Complete Blood Count EXAMINATION (APE) Urinalysis -To be scheduled by your HR / Fecalysis Benefits Administrator in coordination with IntelliCare Chest x-ray Physical Examination Pap smear (for women 35 years old and above of if prescribed by attending physician) Electrocardiogram (for 35 years old and above or if indicated by attending physician)
    • • Routine Immunization (except cost of vaccines)• Counseling on health habits and quarterly Wellness Programs (upon request)
    • • Medical Consultations with IntelliCare affiliated doctors• Referral to IntelliCare accredited specialists• Treatment of minor injuries such as lacerations, mild burns, sprains and the like• Laboratory, x-ray, and other diagnostic procedures prescribed by an IntelliCare accredited physician• Minor surgery not requiring confinement• Pre- and post-natal consultations with any IntelliCare affiliated OB-GYN up to 14 sessions/year.• Speech / Physical Therapy up to 12 sessions per year.
    • OUT-PATIENT1. GO TO OP POS terminal in an accredited clinic or hospital. Present your card (Hospital staff will swipe your card to validate membership status)2. Coordinator of accredited hospitals. Present Intellicare card and LOE3. Secure Intellicare referral slip* (RCS 1 OR RCS 2) prior to any consultations / treatment diagnostic tests/lab procedures4. Present Intellicare card and RCS to accredited doctor or area where the procedure will be done.5. Avail consultation / treatment or procedure (sign RCS after)6. File Philhealth for Philhealth required procedures
    • • Room & Board Accommodation within the limits of the PLAN• Professional fees of attending IntelliCare affiliated physicians• Diagnostic procedures referred by the attending IntelliCare affiliated physicians / specialists.• Administered Medicines either orally or intravenously
    • • Transfusion of blood and intravenous fluids• Anesthesia and its administration• Standard nursing care services, standard admission kit, sutures, dressings, plaster casts, and other items directly related to the medical management of the patient• Use of Intensive Care Unit• Use of Operating Room & Recovery Room facilities• Assistance in administrative requirements through the IntelliCare Patient Relation Officers• Ambulance Service (hospital to hospital) to be covered thru reimbursement up to Php 3,000/member/year.
    • IN-PATIENT1. GO TO (In-patient) IP POS terminal in an accredited clinic or hospital. Present your card. (Hospital staff will swipe your card to validate membership status)2. Proceed to admitting section and present your LOE and admitting orderOCCUPY ALLOWED ROOMINVOLUNTARY UPGRADING- Member are allowed to occupy a room one level higher than what he is entitled to due to non availability for up to 24 hours (1 day) w/oincremental charges (except suite room). After 24 hours (2nd day) whetherRoom becomes available or not, incremental charges will be billed tothe account of the member.*You must transfer once your room becomes available, otherwise,pay all incremental charges *starting from the first day of confinement.VOLUNTARY UPGRADING *Pay ALL Incremental charges from first day of confinement -30% increment in hospital services. -Room and board difference. -Professional fee difference.3. File your Philhealth before hospital discharge *Non-filing or late filing of Philhealth AND *Non-Philhealth members must pay the Philhealth portion upon discharge4. Sign RCS and hospital bill and settle miscellaneous charges upon discharge
    • • life-threatening situations ACCREDITED NON- FOREIGN requiring urgent medical HOSPITALS ACCREDITED TERRITORIES or surgical care e.g. heart HOSPITALS attack, stroke, poisoning, Covered up Covered thru Covered thru loss of consciousness or to MBL reimbursement reimbursement respiration and up to 30,000 up to 30,000 convulsion Hospital bills – Hospital bills – Hospital bills – 100% 80% of IntelliCare 80% of IntelliCare Intellicare RVS RVS RVS Professional Professional fees Professional fees fees – 100% – 80% of – 80% of IntelliCare IntelliCare RVS IntelliCare RVS RVS *RVS (Relative Value Scale)
    • EMERGENCY CARE PROCEDURES1. GO TO the Emergency Room of an accredited clinic or hospital Hospital staff will swipe your card to validate membership status2. Undergo medical treatment3. If declared as an outpatient case only, do not forget to sign RCS and hospital bill upon discharge and settle non-covered charges4. If for admission, notify Intellicare Customer Service within 24 hours. Occupy allowed room. ( incremental charges will apply during room upgrading5. If treated in a non-accredited hospital, you may file reimbursement of your medical bills upon discharge
    • 1. Secure IntelliCare Reimbursement Form and fill up completely.2. Complete the following documents and attach to the Reimbursement Form: a. OUTPATIENT Original Official Receipt (with TIN) Statement of Account from the hospital Medical Certificate* Laboratory result (if with diagnostic procedure)
    • REIMBURSEMENTS – cont…. b. IN-PATIENT Original Official Receipt (with TIN) Medical Certificate* Statement of Account (Itemized Hospital Bill) Operative Record with Histopath Result (if with operation) Police Report & Medico-Legal Report (if required)NOTES:• Submit to IntelliCare not more than 30 days from expiration of treatment• IntelliCare will process the request within 20 working days upon receipt of complete documents
    • *MEDICAL CERTIFICATE
    • • First dose of anti-rabies, anti-venom and anti-tetanus are covered up to PHP 15,000.00.• Congenital illnesses shall be covered for Principal members shall be covered up to PHP 20,000.00 per illness / member / year.• Cautery of warts up to PHP 1,000.00 / member / year.
    • Lithotripsy = PEC limitLaparoscopic Procedures = PEC limitArthroscopic / Hysteroscopic Procedures = PEC limitTransurethral Microwave Therapy of Prostate = maximum of 50,000Percutaneous Ultrasonic Nephrolithotomy = PERC limitHeart Surgery / Angiogram = up to 50,000Neuroscan = PEC limit
    • Perfusion Scan = PEC limitMagnetic Resonance Imaging (MRI) = PEC limitNuclear Radioactive Isotope Scan (NRIS) = PEC limitChemotherapy / Radiotherapy = PEC limitUltrasound (except maternity cases) = PEC limitDialysis = PEC limitCT Scan = PEC limit
    • Notes on Availment of Latest Modalities of Treatment & Special ProceduresProcedures mentioned are covered up to the limits indicated orPEC limit (whichever is lesser)Other modalities of treatment and/or diagnosis requiringsophisticated equipment and performed by highly skilledtechnicians or specially trained doctors for which there are nocomparable conventional or traditional equivalents / counterpartswill have a maximum limit of Php5,000 subject to the exclusionsand limitations of the contract
    • Dental ExaminationBi-Annual Oral ProphylaxisSimple tooth extractionTemporary fillingsTwo (2) teeth permanent lightcure fillingsRecementation of jackets, crown, inlays and onlaysTreatment of minor gum problems, mouth lesions, wounds and burnsOrthodontic consultations (braces and malposition of teeth)Temporo mandibular joint consultation (clicking of jaws)Pre-natal check of teeth and gumsEmergency dental treatment for the relief of painDental health education
    • DENTALCheck out list of IntelliCare Accredited DentistsCall dentist to find out if they implementFIRST-COME , FIRST-SERVED or BYAPPOINTMENT policyGo to the ACCREDITED DENTAL CLINICPresent IntelliCare CardAvail of Dental treatment/ consultationSign-off dental referral control sheet afterconsultation / treatment
    • Natural Death - Php 10,000.00Death due to Accident - Php 20,000.00Loss of both hands - Php 10,000.00Loss of both feet - Php 10,000.00Loss of sight (both eyes) - Php 10,000.00Loss of one hand and one foot - Php 10,000.00Loss of one hand and sight on one eye - Php 10,000.00Loss of one foot and sight on one eye - Php 10,000.00Loss of one hand or one foot or sight on one eye - Php 5,000.00 NOTE: Provided, that the death or injury results from causes that are covered and not under the exclusions provision.
    • PROCEDURES FOR AVAILMENT (Financial Assistance)1. Secure IntelliCare Reimbursement Form and fill up completely.2. Complete the ff: documents and attach to Reimbursement Form: a. Filled up Internment Assistance Form b. Attending Physician’s Certification c. Certified original copy of Death Certificate d. Certified original copy of the deceased and the beneficiary’s Birth Certificates e. Certified original copy of Marriage Contract f. Latest DTR (Daily Time Record) g. Police Report and Autopsy (if accidental death)NOTE: IntelliCare will process the request within 30 days upon receipt of complete documents
    • 1. Services rendered by non-accredited doctors, except with the prior written authorization of an IntelliCare Coordinator, or in Emergency cases2. Hospital charges for special or private nursing services, supplemental foods and medicines like vitamins and minerals (unless prescribed), extra accommodation and non-medical personal appliances such as radio, television, telephone, computer and refrigerator3. Health / Annual / Pre-employment check-ups for other companies, government requirements, insurance purposes or travel abroad4. Recuperation such as confinement in a sanitarium or convalescent home, rehabilitation medicines, custodial, domiciliary care, government imposed quarantines
    • GENERAL EXCLUSIONS / LIMITATIONS – cont…5. Medical Certificates6. Professional fees in medico-legal cases7. Refusal to undergo recommended treatment or demanding treatment for which IntelliCare doctors believe a professionally acceptable alternative exists8. Vaccines for immunization, anti-rabies, anti-venom, steroid injection9. Out patient medicines and medical supplies except in emergency cases10. Procurement or use of eye glasses, special braces, steel implants, wheelchairs or prosthetic appliances including but not limited to items such as artificial limbs, hearing aids, crutches, intra-ocular lens, contact lenses, artificial hips or joints, pacemakers, mesh (for hernia), stents and ventilating tubes
    • GENERAL EXCLUSIONS / LIMITATIONS – cont…TREATMENT AND PROCEDURES1. Determining / Ruling out PEC during the first 12 months of membership if result is positive2. Determining / ruling out of hepatitis or tuberculosis if result is negative3. Circumcision, infertility or fertility and virility/potency (erectile dysfunctions), artificial insemination, sex change4. Laser eye surgery for myopia or error of refraction5. Acupuncture, chiropractic treatment, iridology, chelation, cell implant theraphy6. Speech or Physical therapy in excess of 12 sessions
    • GENERAL EXCLUSIONS / LIMITATIONS – cont…7. Reconstructive surgery (except to treat a functional defect directly caused by accident or illness covered herein), cautery of warts, milia, xyringoma, facial moles, aesthetic, cosmetic or beautification alterations8. Hypersensitivity tests to check for allergies and desensitization9. Sleep study (unless directly related to an organic illness covered up to 5,000)10. Blood screening11. Organ transplants or acquisition of an organ
    • GENERAL EXCLUSIONS / LIMITATIONS – cont…EXTERNAL FORCES / ACTIVITIES1. War-like or combat operations, government declared acts of rebellion, active participation in riots or demonstrations, strikes or labor disputes, terrorism, provoked criminal acts, violation of a law or ordinance, commission of a crime whether consummated of not, serving in the military, naval or air forces of any country or international authority, unnecessary exposure to imminent danger of hazard, active participation in setting of and/or handling pyrotechnic materials, attempted suicide, self-inflicted injuries2. Participation in hazardous activities such as skydiving, motor sports, judo, karate, taekwondo, boxing, wrestling, bungee jumping, scuba diving, snorkeling, horseback riding, polo, hunting, mountain climbing, rock climbing, hang gliding, spelunking, ballooning, gymnastics or partaking as a paid professional or semi-professional in any sport
    • GENERAL EXCLUSIONS / LIMITATIONS – cont…3. Government declared epidemics, complete or partial destruction of hospital by fire, flood, or other perils, earthquake, tsunami, volcanic eruption, acts or order of Government, brownouts4. Aviation or aeronautics use or sea travel other than as a fare- paying passenger on a licensed aircraft/vessel operated by a recognized airline/operatorILLNESSES / CONDITIONS1. Congenital abnormalities such as neonatal hernia, indirect hernia, hemangioma, phimosis, harelip, clubfoot, cerebral palsy, renal diseases such as medullary sponge kidney, pediatric cardiovascular work-up and the like2. Neuro-developmental disorders such as ADHD (attention Deficit Hyperactivity Disorder) Autism, Genetic disorder, which may result to mental retardation (e.g. Down Syndrome) and other conditions which may require speech/physical and other related therapies
    • GENERAL EXCLUSIONS / LIMITATIONS – cont…3. Sexually-transmitted diseases, AIDS and AIDS-related complex or condition4. Substance addiction or reaction to use of prohibited drugs, alcoholism, alcohol intake, anxiety reaction, psychiatric and psychological illnesses,neurotic and psychiatric behavior disorders, or accidents arising from these conditions5. Guillain-Barre syndrome6. Developmental delay7. Any illness or disability which may have affected a dependent prior to the 30th day after birth8. Pregnancy, childbirth, miscarriage, pregnancy-related illnesses, abortion, post-natal care
    • Always present your IntelliCare Membership Card and another valid ID during availment. Lost card – report to IntelliCare immediately PHP 100.00 – replacement fee for lost card
    • MANILA (0920) 951-8452 – Smart (0917) 805-2502 - Globe BRANCH OFFICES CEBU (032) 255-1282 (0920)-9073708 BACOLOD (034) 433-1984 (0920) 926-8649 CDO (08822) 726327 (0920) 951-9526 DAVAO (082) 227-4697 (082) 227-4621 (0920) 951-9523E-MAIL ADDRESS:intelli_act@intellicare.com.ph
    • Intellicare Makati Clinic Clinic Hours: Monday-Saturday / 8am to 5pm 2nd floor PNB Beneficial Bldg., 166 Salcedo St., Legaspi Village, Makati City Tel. 888-5556 / 830-2320 / 818-8671 local 200 Intellicare Alabang Clinic Clinic Hours: Monday-Saturday / 8am to 5pm Unit 53-10 to 20 Green Bldg. – South StationAlabang-Zapote Road, Alabang, Muntinlupa City Tel 386-6435 Intellicare Ortigas Clinic Clinic Hours: Monday-Saturday / 8am to 5pm Ground Floor, AIC Grande Tower, Sapphire St., Ortigas Center Tel. 706-3844 Intellicare Cebu Clinic Clinic Hours: Monday-Saturday / 8am to 5pm Unit 203 2/F TGU Tower I.T. Park Asiatolon, Apas, Cebu City Tel. 231-0660/61/62/63
    • Intellicare Calamba Clinic Clinic Hours: Monday-Saturday / 8am to 5pmUnit S-5, S– 9 to 10 Daniel Commercial Complex, Old National Hi-Way, Brgy. Parian, Calamba, Laguna Tel (049) 545-4446/(049) 545-5183 Intellicare Sta. Rosa Clinic Clinic Hours: Monday-Saturday / 8am to 5m Unit 26 & 27 Sta. Rosa Commercial Complex, Balibago, Sta Rosa City Laguna Intellicare U.N. Avenue Clinic 801 United Nations Ave., Ermita, Manila Tel 521-8108 / 536-3906 Intellicare PCS Clinic 2nd Floor Philippine College of Surgeon Bldg., 992 North Edsa, Quezon City Clinic Hours: M-Sat 8:00am-5:00pm Tel. # (02) 929-5127 / 929-5412
    • Illnesses diagnosed or pathogenesis has started beforeenrollment or during the first year of membership with IntelliCare,with or without the member’s knowledge.Includes Dreaded Diseases, which are chronic or irreversibleillnesses present prior to enrolment.
    • The following are considered as PECs:Hypertension Hemorrhoids and anal fistulaeThyroid disease, Goiter Tumors(hypo / hyperthyroidism) Uterine myoma, ovarian cyst,Cataracts / Glaucoma / Pterygium endometriosisENT conditions requiring surgery Buerger’s diseaseBronchial asthma Varicose veinsTuberculosis ScoliosisChronic cholecystitis, cholelithiasis Arthritis(gallbladder stones) and other forms ofcalcification Chronic allergiesHernia Gastric and Duodenal ulcersProstate disorders
    • The following are classified as dreaded diseases: Stroke, Paralysis, Epilepsy Rheumatoid arthritis, systemic lupus erythematosus Poliomyelitis, Meningitis, Encephalitis and other neurosurgical conditions Injuries from previous accidents Coronary, Valvular and Hypertensive Single or multiple organ failure requiring Heart Diseases dialysis Asthma, Chronic Bronchitis, Emphysema Burns (if occuring prior to enrollment) Cirrhosis, Hepatitis, Newgrowth Cancers, Leukemia, Idiopathic Thrombocytopenic Purpura Urolithiasis, Obstructive Uropathies Diabetes mellitus, diabetes insipidus Chronic gastrointestinal tract diseases requiring bowel resection and/or ICU confinement and other illnesses anastomosis requiring an extended stay in the hospital for an uninterrupted period of 15 days
    • For any concerns or questions regarding Philhealth: Benefits & Coverage Eligibility Membership/Payments/RequirementsPlease consult your Human Resource Department or visit theirwebsite at www.philhealth.gov.ph