At the pre-authorization process, what is the meaning of the criteria “medically necessary” ?
The meaning of “Medically necessary” is a medical service or medication prescribed by a doctor with the following qualifications:
Common and usual, and
Is for direct treatment of illness/ wound, and
Precise and consistent with the complaint, symptoms, diagnose and treatment of illness/ wound, and
Based on the valid doctor’s practice standard, and
Not for profit earning purpose or for the benefit of insured member or Doctor or hospital or other medical institutions.
This criterion is used as consideration to provide the approved guarantee letter from Allianz to the member.
What is the meaning of medication/ treatment “common and usual” ?
Common and usual means:
Why Allianz does not approve a pre-authorization process ?
Causes of pre-authorization failure:
What if Allianz consider that a referred treatment or hospitalization is not according to the medical service guideline ?
What conditions are classified as an emergency ?
Emergency: a medical treatment which is needed and cannot be postponed after an incident or within 24 hours after an incident to save a life or prevent a permanent disorder.
Conditions that are considered as emergencies are:
An emergency is confirmed by the doctor conducting the treatment, not by the patient or family of patient.
The room and board of the member is Rp. 100,000 per day. But at the Allianz provider hospital, visited by the member, only has 3rd class with room and board of Rp. 75,000 and 1st class of Rp. 125,000 per day. What should I do ?
There are several alternatives that could be done by the member :
Choosing a hospital other than what have been regulated above, might cause an excess claim to occur.Example of calculating a benefit*):
Period of Treatment = 3 days
Plan of Member(IP 100)
Total Expenses(IP 125)
Total Expenses based on plan
Room and Board
100,000 per day
125,000 per day
If a member takes a room and board higher than his/ her plan/ class, then:
Total claim is Rp. 4,525,000
Total payment based on the member’s table of benefit is Rp. 3,675,000
The difference of Rp. 850,000 is called the excess claim
*This regulation is valid according to each regulation stated in the policy book that is still valid.
How to minimize excess claim ?
Excess claim is a result of going through a treatment that is not according or going over the benefit on the table of benefit of the member. Due to that, it is suggested to all members to wisely choose the hospital and room and board that is according to the table of benefit.
I am a member of the group insurance:
1. What if I lost my membership card at the time I need to be hospitalized ?
2. Could I get a new card ?
1. What to do :
· Member should contact the HRD of his/ her company and ask to send to Allianz a written statement explaining the lost card and to send a letter requesting guarantee.
· Upon receiving the written statement on the lost card and guarantee request letter, Allianz medical hotline staff will assist on the pre-authorization process to the hospital where member is being treated.
· If the pre-authorization process is not approved by Allianz, then the member should settle the payment and later do a claim by reimbursement.
2. Member could apply for a new card with an administration fee of RP. 10,000. The process takes 14 (fourteen) working days.
Member got promoted and wants to change his/ her medical plan. What should he/ she do ?
Why is “Food Supplement” not covered by Allianz ?
Food Supplement supports the medicine prescribed by the doctor and it does not cure the cause of illness. It is also not considered as standard medication that must be consumed.
For “reimbursement” payment procedure, member should submit claim form including the diagnostic statement from the doctor. What if a member forgot to ask the doctor for the diagnostic statement ?
It is important for the diagnostic statement to be verified by Allianz. Due to that, if a member does not submit it, for certain, the claim will be returned. Member should:
· Contact the medical record department at the hospital/ clinic and ask for the diagnostic statement from the doctor. That information should be written on the form provided at the medical record department and signed by the doctor conducting the treatment.
· After member completed the diagnostic statement from the doctor, form claim and all requirements needed to settle the “reimbursement” could be resend to Allianz. Allianz will process the “reimbursement” within 14 (fourteen) working days since the complete document is received.
How to submit a claim to another insurer ?
a. Member provides a written request to Allianz to claim the remaining costs that are not covered by Allianz to another insurer.
b. Allianz issues a written notification on the claim amount and the amount covered by Allianz.
c. Allianz will prepare copies of receipts that have been paid and legalized those documents, for the member to submit claim to another insurer.
What documents should I submit for claim ?
How to submit a claim that have been submitted to another insurer and the remaining is claimed to Allianz ?
Member sends all copy claim document and receipts that have been legalized by the other insurer along with a written notification from the other insurer on the amount that has been claimed and the amount paid by the other insurer.
What does it mean by “the same hospitalization period is 30 days” ?
The same hospitalization period is a sequence of hospitalization or surgery, from the first day until the last day that the member is hospitalized, including sequence of treatment for the same illness or accident or that is related, which occur 30 (thirty) days from the date the member got out of the hospital.
When a member is treated again with the same illness after 10 days from the last date he/ she was hospitalized, then it is still considered one period of the same hospitalization.
Allianz issued a Surgery Table, what if a member went through a surgery but the classification of surgery applied in the hospital is different than what is applied by Allianz ?
When there is a different surgery classification applied in the hospital, then the valid regulation is the surgery classification according to Allianz Surgery Table.