PMCARE SDN BHD - Medibase

1 PMCARE SDN BHD WORKING GUIDELINES FOR HOSPITALS AND SPECIALIST CLINICS TABLE OF CONTENT ITEM PAGE CHAPTER 1: 1 Introduction 1 Hospital & Specialist Clinic Address 1 Provider Code 1 Identification of PMCARE Member 1 Verification of PMCARE Member 1 Medical Record 1 Exclusions 2 Charges 2 Claims Submission 2 Submission Deadline 2 Deductions From Amount Claimed 2 Appellant 2 Temporary Suspension of Service 2 Termination 2 Communication 3 CHAPTER 2: CONSULTATION AND ADMISSION PROCEDURES 4 Provision of Services 5 For PMCARE Members 5 For PMCARE Premier Card Holder 5 CHAPTER 3: BILLING AND DISCHARGE PROCEDURES 6 Guides on Discharge Procedures 7 For PMCARE Members 7 For PMCARE Premier Card Holder 7 CHAPTER 4: CLAIMS SUBMISSION PROCEDURES 8 Claims Submission Procedures 9 Submission Deadline And Requirements 9 Documents and Information Required for Claims Submission for Reimbursement 9 PMCARE Premier Card Holder 9 CHAPTER 5: EXCLUSION LIST 10 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.

2 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 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.

3 Lastly, we will also appreciate any feedback on the Working Guidelines from you. 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. 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.

4 The provider code shall help to facilitate communication and administer the business arrangement between the Hospital or Specialist Clinic and PMCARE . 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. VERIFICATION OF PMCARE MEMBER Please verify member s identification against another documents ( Identification Card or passport or Guarantee Letter) 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 PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINICS CHAPTER 1 Effective Date: 24/06/2016, Revision 8 2 We reserve the right to review the abovementioned Hospital or Specialist Clinic records for verification of claims.

5 Your Hospital or Specialist Clinic shall provide to us on site review and/or submit to us copy of record for the purpose. 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. 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. CLAIM SUBMISSION Invoices (claims) must be submitted to reach us within thirty (30) days from the service date or date of discharge.

6 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 beyond 30 days. DEDUCTION FROM AMOUNT CLAIMED Deduction of MEPS-IBG charge or 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. 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. 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.

7 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. PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE PANEL OF HOSPITAL & SPECIALIST CLINICS CHAPTER 1 Effective Date: 24/06/2016, Revision 8 3 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.

8 CONSULTATION AND ADMISSION PROCEDURES PROVISION OF SERVICES FOR PMCARE MEMBERS 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.

9 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: 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: Consultation GL valid for fourteen (14) days from date of issuance.

10 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. 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). For EMERGENCY case, please attend to our members immediately and subsequently call PMCARE to request for a GL.