Others

Pre-Approval / Precertification
     • Pre-certification / pre-approval form
          • Claim Form (if no pre-certification form)
          • Filled-up and signed by member and physician
     • Laboratory and / or Diagnostic Results
     • Name of surgery, if any
     • Cost estimate with breakdown of:
          • Professional Fees (Attending, Surgeon, Anesthesiologist)
          • Hospital Fees
          • Other items
     NOTE: PLANNED ADMISSIONS/SURGERIES MUST BE FILED 10 DAYS PRIOR TO THE SCHEDULED DATE

Treatment Plan for Physio / Chemo / Radio Therapy Treatments
     • Treatment Plan Form
          • Claim Form (if no treatment plan form)
          • Filled-up and signed by member and physician
     • Laboratory and / or Diagnostic Results
     • Cost Estimate with breakdown of:
          • Number of sessions and schedule dates
          • Name of chemo drug or radioactive to be used
          • If Physiotherapy, procedure to be done
     • For additional sessions:
          • Physiotherapy report or;
          • Oncology Report
          • supporting Diagnostic Reports

Follow-Up Care Treatment
     • Follow-up Claim Form
     • Doctor’s Prescription
     • Original Official Receipts
     • Lab request and result

Dental
     • Dental Claim Form
     • Dental Report
     • Original Official Receipts
     • Itemized Breakdown of SOA:
          • Treatment done
          • Tooth number

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