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
MARSH 208 January 2020
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
Group Hospitalization and Surgical
Period : 01 Jan 2020 – 31 Dec 2020
MARSH 408 January 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
MARSH 508 January 2020
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
MARSH 608 January 2020
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
MARSH 708 January 2020
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
MARSH 808 January 2020
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)
MARSH 908 January 2020
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
MARSH 1008 January 2020
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)
MARSH 1108 January 2020
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
MARSH 1208 January 2020
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)
MARSH 1708 January 2020
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
MARSH 1808 January 2020
Claim Form
MARSH 1908 January 2020
Inpatient Receipt
MARSH 2008 January 2020
Inpatient Billing Detail
MARSH 2108 January 2020
Medical Resume Laboratory result
Medical Resume & Laboratory Result
MARSH 2208 January 2020
REJECTED PAYMENT RECEIPT - SAMPLE
MARSH 2308 January 2020
Diagnose must be written by the DoctorDoctor’s stamp and
signature
Patient’s name
ACCEPTED PAYMENT RECEIPT - SAMPLE
MARSH 2408 January 2020
Sample of Claim Document
Outpatient – Medicine Receipt
Patient’s name
Pharmacist’s
stamp
Name &
address of
the
Pharmacist
Copy
prescription
ACCEPTED PAYMENT RECEIPT - SAMPLE
MARSH 2508 January 2020
Example of Official Receipt (Overseas Treatment)
MARSH 2608 January 2020
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