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HMO related queries are among the most that we receive. Here are some of them.

1. Who are qualified members?
The qualified principal members must be at least 18 years old but not more than 65 years old
2. Who are eligible dependents?
A. Married Principal Member: Legal spouse not more than 65 y/o, legitimate child from 15 days old but not more than 21 y/o single and unemployed. Illegitimate child can be declared provided that the birth certificate is duly-acknowledged by his/her father.
B. Single Principal Member: Parents not more than 65 y/o. If both parents are no longer qualified, brother/sister can be enrolled provided not more than 21 y/o, single & unemployed. No substitution of sibling if only 1 parent is qualified.
3. How many dependents are allowed?
Enrollment of dependents depends on the company on up to how many they would allow for as long as hierarchy-rule will be strictly followed (based on law for insurance).
4. Is it possible for the insured to change dependents?
Yes, provided the dependent is covered on the corporate account and he/she is qualified
5. What if the benefit card expires and the cardholder needs to visit the doctor for treatment?
Naturally, benefit cards with expired validity date will not be honored. However, if name of the member is included in the renewal list submitted by the company to the healthcare provider while new benefit cards are still being processed, availment of the member can be covered “manually”. Meaning, availment should be coordinated with Trinity or to the healthcare provider before proceeding to the hospital or clinic of the doctor to ensure coverage of the member.
6. In case of accident and the insured is under the influence of alcohol and is found not to have provoked the accident, will the hospitalization be covered?
Yes
7. Is it possible for the insured to transfer the benefit of one dependent to the other to enable the latter to avail of the benefits?
No. The hierarchy of dependent enrollment does not allow this.
8. In case of non-availability of the allowed room type provided for by the coverage, would the insured be liable to pay for the incremental costs in case he/she chooses n upgraded room type?
Yes. If the policy has no special benefit for room upgrade and the insured wants to avoid the additional expenses, room downgrading is suggested.
9. What happens if the personal doctor of the insured with whom the latter has previous records with is not accredited?
The patient can request for accreditation but subject for evaluation or he would have to transfer to an accredited doctor for that matter.
10. During emergency cases and there is no accredited doctor or hospital, what would the insured do?
The E.R. officer on duty will then take charge. If member needs to be confined, he will have to choose a room according to his plan. All expenses incurred during emergency in a non-accredited hospital will have to be paid by the member. After which, he/she can file for reimbursement from the provider upon discharge. The amount to be reimbursed is limited only up to the specified HMO rate benefit limits stipulated in the policy.
11. What should be done if an accredited doctor asks the insured to cash out and pay for the professional fee?
Don’t pay. Call the healthcare provider for assistance.
12. Is upgrading of plan allowed as requested by the cardholder?
Upgrading of room during members confinement is strongly discourage to avoid from paying the room and board difference and incremental costs.
13. What happens if a cardholder, who does not have a maternity benefit under her plan, undergoes a diagnostic test and was later found to be pregnant - will her test be covered?
No. The diagnostic test will be billed back to the patient.
14. Could a cardholder carrying two HMO cards (one as employee and one as dependent) use both card at the same time?
No. The insured must first exhaust the benefit of one card before the other can be applied. He has to choose which to use first and should follow the benefits according to the plan limit. But he can use the 2nd card as supplementary to the 1st card as long as the 1st card has been exhausted.
15. Is it okay to apply for a 1-time issuance of LOA for the maximum number of therapy sessions covered under the insured’s plan?
No. A maximum of only three LOA’s can be issued at one time.
16. If the medicine prescribed by the doctor during an in-patient confinement is not available in the accredited hospital and thus requires that it be purchased outside the hospital, can the member have the cost reimbursed?
Yes so as long as the medicine is a necessary in-patient medication. A letter must be executed and signed by the member explaining the reason why the cost should be reimbursed. All official receipts for the purchase with the doctor’s prescriptions must be attached to the said letter..
17. If a cardholder undergoes an out-patient consultation / diagnostic tests upon the insured’s own volition for screening purposes and the results are negative, are the diagnostic procedures cost and consultations fee eligible for reimbursement?
No as the nature of the check-up is not borne out of any symptoms of any particular covered illness or condition.
18. Can the cardholder be informed of his utilization?
Yes. Even date of reference will be provided though the more recent utilization may not yet be included or reflected.
19. Can the PT sessions, radio therapy, chemotherapy, and dialysis be independently used up to the policy’s Maximum Benefit Limit.
No. These procedures are subject to various inner limits based on the policy.
20. How do you go about replacement of lost benefit card?
Present affidavit of loss and pay the card replacement fee to facilitate re-issuance of lost card.
21. Do you have to be a member of Philhealth?
Yes, all insured Principal must be an ACTIVE Philhealth member.
22. How does the Philhealth benefit apply to the Room & Board and to the total hospital bill?
HMO Benefit is incorporated with Philhealth. It applies after Philhealth Coverage had been exhausted. If there was an upgrade of room & board but falls under the same room category (i.e.: Small Private to Large Private whereas the policy covers only for Small Private,) only excess for room & board will be charged to the patient. If however room & board was upgraded to a higher room category (i.e.: Small Private to Suite whereas the policy covers only for Small private,) the member will be charged for the excess in room & board and all incremental cost on the hospital bills and professional fees.

Since Philhealth is incorporated w/ HMO plan, it should be filed prior to discharge otherwise, it will be shouldered by the patient and will be collected by the hospital. Filing of Philhealth reimbursement is subject for evaluation by Philhealth Claims Department.
23. As incremental charges are dependent on the type of room category utilized, how do you compute for the incremental cost?

The Incremental Cost formula is as follows:

(Total Hospital Bill) - (Actual Room/Board Charges) - (Disapproved Charges) X __ %

Note: The percentage varies on the room & board upgrade. For one level upgrade, translates to 20%. For two level upgrade, 30% and for three level upgrade and higher, it is 50%.

24. Is there benefit coverage of Philhealth for special procedures?
Yes. This is true for scheduled OPD procedures like chemotherapy & cataract extraction.
25. Could the cardholder just pay Philhealth on cash and reimburse the sum after discharge?
Yes
26. Can a member pay for the Philhealth portion in advance and just file for reimbursement after being discharged?

Yes. However, the member has to secure a waiver from the HMO certifying that the Philhealth portion was settled by the member in advance. Thereafter, the Philhealth Reimbursement procedure is as follows:

a. Secure and Philhealth Form 1 – from your HRD or hospital (fax copy or photocopy
not allowed)
b. Form 2 - hospital (to be filled up by the doctor once discharge order was issued)

27. HMO Accredited Network

Cocolife • Intellicare • Medicard Philippines • Valucare



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