socialization group health, life and personal …...intensive care unit ( icu ), per person / day -...

HOSPITALIZATION AND SURGICAL LIFE AND PERSONAL ACCIDENT INSURANCEVMWARE SOFTWARE INDONESIA

1 Jan 2020 – 31 Dec 2020

MARSH 108 January 2020

Objective

All party should understand :

• Current Program

• Benefit

• Exclusion

• Service Procedures


Providers

• Risk Consulting

• PT. MARSH INDONESIA

Sentral Senayan II, Lt. 15

Jl. Asia Afrika No. 8

Jakarta 10270

• Tel. 021 5790 0110

• Fax. 021 5790 0120

• Marsh Helpline : 0811 – 8886694

(After working hours, including holiday)

• Insurance

• PT. AIA FINANCIAL

AIA Central

Jl. Jend. Sudirman kav. 48A

Jakarta Selatan

• AIAF Client Services

Tel. 021 5421 8888 (office hour)

Email. [email protected]

• 24 hour Contact Number

Tel. 021 1500980

mailto:[email protected]

Group Hospitalization and Surgical

Period : 01 Jan 2020 – 31 Dec 2020


Participant

• ACTIVE EMPLOYEE

– Entry Age : 16 – 59 years old

– Renewal : up to 64 years old

• DEPENDENTS

– Spouse : 16 – 59 years old

– Child : 0 days up to 25 years old*

*Student, unmarried, unemployed


Participant

IMPORTANT !!

• Informed to HR to have you registered

• Informed to HR your new spouse immediately after marital date

• Inform your new born child immediately after the date of birth

• Report for any status changes

• Remind HR should your child has exceed the maximal age


INPATIENT BENEFITLimit (IDR)

Daily Hospital Room & Board, per person / day - max.120 days / disability 1,200,000 Intensive Care Unit ( ICU ), per person / day - max.30 days / disability 2,400,000

In Hospital Doctor Visit, max. 1 visit per day 600,000

Consultation fee for Specialist per day 675,000

Operating Theatre Charges

- Complex

- Major

- Intermediate

- Minor

Anaesthesist's Fee

- Complex

- Major

- Intermediate

- Minor

Surgeon' s Fee

- Complex 100,000,000

- Major 63,750,000

- Intermediate 40,000,000

- Minor 26,000,000

Other Hospital Services 33,000,000

Pre and post Inpatient, 31 days before and 90 days after discharged from hospital

Pre and post diagnostic, x ray, lab test 31 days before and 90 days after discharged from hospital

Emergency Outpatient Treatment due to accident 6,000,000

Emergency Dental Treatment due to accident 4,275,000

Ambulance Fee 750,000

Hospital Cash Plan 1,200,000

300,000,000 Overall Annual Limit

INPATIENT

Cover under Surgeon's fee

Cover under Surgeon's fee

7,500,000


Terms & Conditions

• 100% cashless facility and reimbursement, no co sharing

• Waive pre-existing conditions for all members

• Reinstatement benefit 0 day

• Claim Reimbursement Process is 14 working days subject to receiving complete claim

document

• Hospital cash plan with amount as per R&B limit, if member use full BPJS for his/her

hospitalization treatment, as long as no excess claim submitted and paid by AIA. For this

Hospital cash plan benefit, reimbursement system applies


Room and Board

• Occupied the room and board as per your entitlement

• Should the entitled room and board is not available or full, the member can upgrade up to one

level higher from his room entitlement during his treatment in the hospital until discharge.

Other benefits will be covered in accordance to the table of benefit

• Should participant occupying higher room and board as per their own request, than the

benefit payable maintain the inner limit, and the difference between occupied RB and entitled

RB will be paid by the member (from day 1)


MATERNITY BENEFIT

PLAN

Normal Maternity, per pregnancy 10,500,000 Caesar Manternity, per pregnancy 16,000,000

Miscarriage, per pregnancy 5,000,000 Pre/Post-Natal, per year 6,400,000

MATERNITY


Terms & Conditions

• 100% cashless facility and reimbursement, no co sharing

• No waiting period for maternity benefit

• Benefit limit per pregnancy

• Cover female employee and female spouse with age < 45 years old

• Cover delivery by midwife

• Cover health baby in mother’s maternity limit (example: baby well-check up)

• Cover pre & post natal care including Torch and USG 4 dimension

• Pregnancy complication is covered in Inpatient (if member has to be hospitalized and not

ended with termination/delivery of the baby)


Exclusions

• Injuries arising directly or indirectly from war, declared or undeclared

• Special nursing care; non medical personal and services such as radio, telephone;

and use of special equipment

• Treatment/surgery for cosmetics and communicable disease requiring isolation or

quarantine under the law

• Routine physical examinations and any treatment which is not medically necessary

• Eye refraction, eye glasses; hearing aids; and any dental treatment/surgery (except

due to accident)

• Treatment or surgery for congenital anomalies; treatment relating to birth control,

illegal abortion, sterilization, and infertility

• Treatment for functional disorder of the mind; self-inflection; drug addiction,

alcoholism

• Alternative medication/treatment


Cashless System

Member’s insurance card to be given to each member

AIA Admedika call centre no can be found at the back of the card

MARSH

Data Peserta Dikirim Secara On-

Line Melalui Sambungan Telepon

Ke Admedika

2Kartu ADMEDIKA Digesekkan

Ke EDC Terminal serta dimasukkan

Kode Terminal Diagnosa

Pemegang Kartu Ke

Rumah Sakit

Untuk Perawatan

Pemegang Kartu / Pasien

Langsung

Menjalani Perawatan Rawat Inap

4

Surat Jaminan / Surat Penolakan

Akan tercetak dari EDC terminal sesuai

dengan manfaat Polis (Dalam waktu 30

detik)

3

1

Pemegang Kartu

Menunjukkan Kartu

Kepesertaan

Kartu Kesehatan

AdMedika

BAGIAN PENDAFTARAN

RAWAT INAP

Pemegang Kartu / Pasien perlu

Menandatangani Surat Jaminan

Yang tercetak dari EDC termnal.

5

Cashless Procedure in AIA-Admedika’s provider

MARSH

Cashless Procedure in AIA-Admedika’s provider

1

Sebelum Pasien Pulang/ keluar dariRumah Sakit, Petugas diBagian Kasir harus mengirimkan FaxRincian Tagihan dan Formulir ResumeMedis Ke Bagian Operasi PemegangPolis

4 Setelah itu PASIEN LANGSUNG PULANG(SEBELUM PASIEN PULANG)

BAGIAN JAMINAN

BAGIAN OPERASIADMEDIKA

Petugas Pemegang Polis akan mengverifikasikan Diagnosa Akhir dan Biaya Rawat Inap, dalam waktu kurang dari 30 menit

2

Pihak Rumah Sakit akan menerima Surat Pengesahan Biaya Rawat Inap dari Bagian Operasi Pemegang Polis melalui fax

3

BAGIANPEMBAYARAN(KASIR)

RAWAT INAP

MARSH

EXCESS CLAIM

Excess claim to be paid on the spot (at the time of discharge)

WHY IS THERE ANY EXCESS CLAIM ?

1. If member is using Room & Board exceed his/her room entitlement

2. Hospital expenses exceed the limit of benefit

3. The diagnose is the policy’s exclusion

4. No medical indication

5. Non medical expenses

Such as : TV rental, diapers, newspapers, laundry etc

Note:

Eventhough excess is paid on the spot, there is possibility that there will be additional excess

charge after documents are received from hospital and be further analysed by Admedika

MARSH

Reimbursement Procedure

Treatment at non AIA-ADMEDIKA provider

EOB will be sent to

each member’s e-mail

(Claim process max.

14 working days after

documents completely

received by AIA)


Claim Procedures outside Providers

• Free to choose any hospital

• Claim reimbursement submission within 60 days from date of treatment

• Completed claim Form

• Original Receipt, stamp duty and detail billing

– Stamp duty for amount above IDR 1.000.000 : Rp6.000

• Detail of medicine, doctor reference for diagnostic test (Lab, X-ray), copy of

diagnostic test result, medical resume

• For hospitalization overseas, should submit Official Receipt and tax invoice. The

claim document should be in English language

• Claim reimbursement within 14 working days from completed documentation

received by Insurer


Claim Form


Inpatient Receipt


Inpatient Billing Detail


Medical Resume Laboratory result

Medical Resume & Laboratory Result


REJECTED PAYMENT RECEIPT - SAMPLE


Diagnose must be written by the DoctorDoctor’s stamp and

signature

Patient’s name

ACCEPTED PAYMENT RECEIPT - SAMPLE


Sample of Claim Document

Outpatient – Medicine Receipt

Patient’s name

Pharmacist’s

stamp

Name &

address of

the

Pharmacist

Copy

prescription

ACCEPTED PAYMENT RECEIPT - SAMPLE


Example of Official Receipt (Overseas Treatment)


Example of Tax Invoice (Overseas Treatment)

MARSH

FAQ

Upgrade Room and Board

How if member upgrade room and board on own request?

• Answer: If a member upgrade room and board as their own request, the difference for room and board and

other excess (if any) will be born by the member.

Category surgery

Who is determined the category for any surgery?

• Answer : It is decided by Insurer upon receiving the medical data. Insurer has the list consist of the surgical

category.

List of Hospitals

How can member know the updated provider list?

• The updated providers listing will be sent monthly to HRD, or member can ask to AIA customer care or

check on AIA’s mobile application

Sharing the limits

Can employees limit be shared with dependents?

• Answer : No. It should be based on policy guideline. The benefits limit is based on market study and

practice.

2708 January 2020

socialization group health, life and personal …...intensive care unit ( icu ), per person / day -...

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