Group Health Claims

Group Health Claims

Group Health Claims

As a valued customer of Alliance Insurance Group, you may find and fill the required documents for all Group Health Claims. To help the service provider respond quickly and efficiently to your inquiry, please make sure to duly fill each of the required information

Process

CLAIMS SUBMISSION PROCEDURE

CASH /REIMBURSEMENT CLAIMS SUBMISSION PROCEDURE

The Insurance Company will pay for Covered Expenses, up to the limits and sub-limits shown in the Schedule of Benefits, incurred by an insured person in a year, which exceed the Deductible shown in the Schedule of Benefits. Benefits will be paid at the Coinsurance rate shown in the Schedule of Benefits.

All claims incurred outside PPO Network should be reported to your insurer within 30 days from their dates of occurrence along with all necessary claim documents.

Out-Patient Treatment

Original Claims Document(s) to be attached for the Out- Patient Claim

1. Indemnity Medical Claim Form fully completed by insured, employer and attending physician

2. Official Receipt for Consultation and other services.

3. Breakdown of charges.

4. Results of Lab Test, X-rays and other examinations performed (copies can be attached).

5. Doctor’s Prescription.

6. Itemized Pharmacy Bill showing the date of purchase and name of the patient.

In Patient Treatment

Original Claims Document(s) to be attached for the In-Patient Claim:

1. Indemnity Medical Claim Form fully completed by insured, employer and attending physician

2. Itemized Hospital Invoice

3. Official Receipt from the hospital stating the total amount paid

4 .Detailed Hospital Discharge Report

Please note that well-documented claims, which are received by the insurers within the reporting time frame, will result in speeding up claims settlements.

Treatment Procedure

Out Patient

• When you visit a Provider within your Insurer’s Providers Network (PPO), make sure to present your Insurance and ID Cards.

• You will be asked to pay the up-front deductible and/or co-payment at the front desk, as stated in your ID card.

• PPO Hospitals shall be recommended to in-hospital confinement, emergencies and further investigations.

• For emergency cases, the PPO hospital will immediately provide necessary medical treatment and admission will have to be notified to your insurer within 24 hours.

• For non-emergency cases, the PPO Hospital with your insurer will arrange Predetermination Approval Request prior to admission.

NOTE: All medical expenses incurred outside the assigned PPO Network, at an outside clinic in the premises of the hospitals or outside network, should be paid in cash by the insured and the relevant bills / reports should be submitted to your insurer for reimbursement. Your Insurer will reimburse the insured for said expenses according to coinsurance, deductible, geographical scope and reasonable and customary basis.

In Patient Hospitalization

Non-Emergency

All non-emergency inpatient Hospital admissions must be certified in advance by the insurance company.

A Covered Person or his or her attending Physician must call the Insurance Company for certification prior to all scheduled or elective hospital admissions. A pre-approval request form[SS1]  must be filled out and submitted to your insurer.

If the Insurance Company determines that the admission or service is Medically Necessary, the Covered Person will be notified that the Hospital admission has been certified.

If the admission is not authorized, the Covered Person will be advised of this determination.

If the Covered Person does not receive notification prior to the scheduled admission or service date, he or she should contact the Insurance Company to determine the recommendation that it has taken with respect to that Hospital admission.

Emergency

In an emergency Hospital admission, you present your Insurance and ID Cards to the hospital, a request to certify must be made by the hospital within 24 hours or on the next business day following the Covered Person’s admission. “Emergency admission” means an inpatient Hospital admission for an Emergency Medical Condition.

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