Benefit Availment Procedure IMPORTANT NOTICE

1 2 3 4 5 6 Always bring and present your

Intellicare card when availing your
Out-Patient

healthcare benefits (For lost card,

inform your HR immediately. Submit an
Affidavit of Loss and pay the
Go to the POS terminal in an Present your Intellicare If APPROVED, Out-Patient Secure an Intellicare Avail of the consultation or File Philhealth for replacement fee).
accredited hospital or clinic. card to the Intellicare (OP) Letter of Eligibility Referral Control Sheet procedure. Sign the RCS. Philhealth-required
In a hospital, the terminal is Coordinator or to the (LOE) will be printed. (RCS) 1 for consultation procedures.
located at the Intellicare attending medical staff Sign the LOE. or RCS 2 for laboratory
For the list of accredited and
Coordinator’s clinic, at the and have it swiped to or diagnostic procedure affiliated medical providers,
Industrial office, or at the validate membership If DECLINED, the attending prior to availment. you may refer to your guidebook,
HMO office. In a clinic, the eligibility. medical staff will call
terminal is located at the Intellicare’s Customer
Note: If the consultation/procedure is not done yet, please keep the RCS and request Intellicare’s website, or call Intellicare’s
reception area or at the Service for assistance. cancellation through the Intellicare Coordinator or call Intellicare’s 24/7 Customer Service Customer Service for assistance.
nurse station. Hotline. RCS is valid within three days from date of issue.
For concerns or queries regarding your
1 2 3 4 5 6 7 Philhealth benefits and coverage,
eligibility, payments, and
requirements, please consult with your
HR Department or visit
Healthcare
In-Patient

www.philhealth.com.
INDRA PHILIPPINES, INC.
ELECTIVE CASE

If recommended for Proceed to the admitting section Present the admitting order Occupy allowed room The medical staff or File Philhealth for Intellicare’s Patient Relations
admission after undergoing and present your admitting order and LOE to the Intellicare (note: please double-check Intellicare’s Patient Relations Philhealth-required Officer (PRO) will issue an
medical consultation or and Intellicare card. The medical Coordinator. room category/plan limit to Officer (PRO) will inform procedures. Intellicare Referral Control Sheet For accredited hospitals or clinics
diagnostic examination, staff will swipe your card for avoid paying incremental Intellicare’s Customer (RCS) 3 for in-patient. Sign the without POS terminals, proceed to the
validation of membership charges). Service regarding admission RCS. Settle any incremental and
secure an admitting order eligibility. If APPROVED, Intellicare Hospital Coordinator or call
from an Intellicare-affiliated within 24 hours. miscellaneous charges upon
In-Patient (IP) Letter of Eligibilty Intellicare’s Customer Service for
doctor in an (LOE) will be printed. discharge (please validate if items
Intellicare-accredited Sign the LOE. Note: If you had your consultation or diagnostic examination in another clinic or hospital, charged are correct). assistance.
hospital where you will be please present the results and recommendation of the Intellicare-affiliated doctor to the
admitted. If DECLINED, staff will call Intellicare Coordinator for you to be assigned an Intellicare-affiliated doctor in an
Intellicare’s Customer Service Intellicare-accredited hospital where you will be admitted. If your card is not swiped or if no LOE is
for assistance. issued, member may be billed of the
charges (e.g. excluded facility,
Period of Coverage
1 2 3 4 5 6 7 clinic-based, membership status is not
May 1, 2016 to April 30, 2017
active, consultation/procedure is not
covered).
Emergency

Go to the Emergency Present your Intellicare card Undergo medical treatment. If declared as an If FOR ADMISSION, the medical Intellicare’s Patient Relations Officer
staff or Intellicare’s Patient File Philhealth for (PRO) will issue a Referral Control 7th Floor, Feliza Building,
Room (ER) of an to the ER staff for validation OUT-PATIENT CASE,
Relations Officer (PRO) will inform Philhealth-required Sheet (RCS) 3 for in-patient. Sign the 108 V.A. Rufino Street, Legaspi Village,
accredited hospital. of your membership status. sign the hospital bill upon Intellicare’s Customer Service procedures.
If APPROVED, ER LOE will discharge and settle RCS. Settle any incremental and Makati City , Philippines 1229
regarding admission within 24
be printed. Sign the LOE. non-covered charges. hours. Occupy allowed room miscellaneous charges upon
(note: please double-check room discharge (please validate if items
If DECLINED, attending category/plan limit to avoid charged are correct). Website: intellicare.com.ph
medical staff will call paying incremental charges).
Intellicare’s Customer NOTE: If treated in a non-accredited facility, you may file for reimbursement of your hospital bill (subject to plan coverage). Trunkline Numbers:
Service for assistance. The process of reimbursement is as follows: (02) 789-4000, (02) 902-3400
1. Download Intellicare Reimbursement Form from Intellicare’s website or secure a copy from your HR representative.
2. Fill up the reimbursement form completely and attach required documents (please note: all attached official receipts must be original copies). • For calls: Globe - (0917) 840-4894
3. Submit the form and the required documents to Intellicare within 30 days from expiration of treatment/hospital discharge. Smart - (0920) 970-4724
4. Intellicare will process the request within 30 days upon receipt of complete form and documents.
• For texts: Globe - (0917) 805-2502
Smart - (0920) 951-8452
1 2 3 4 5
Cebu:
Room 601 6/F Metrobank Plaza Bldg.,
Dental

Osmeña Blvd. Cebu City

Check the list of Call the dentist to Proceed to the dental Avail of the entitled dental Sign the Referral Control Trunkline Number - (032) 255-1282
Intellicare-affiliated dentists confirm schedule and to clinic on the day of your benefit. Sheet (RCS) 5 made Mobile Number - (0920) 907-3708
(you may refer to your inquire if an appointment dental availment and available at the dental
guidebook, Intellicare’s should be set or if present your Intellicare clinic.
website, or call Intellicare’s walk-in patients can be card for validation. *For feedback or inquiries, e-mail
Customer Service for accommodated. [email protected] intellicare.com.ph
assistance).
 medical management of the patient 7. ADDITIONAL BENEFITS > Hepatitis B except vaccines and screening shall be covered up to
PLAN FEATURES > Assistance in administrative requirements through the > Cauterization of warts shall be covered provided that an accredited the maximum benefit limit per year (if acquired)
Intellicare Patient Relations Officer physician recommends it and only for cases that affect the > Slipped disc and spinal stenosis shall be covered up to PEC limit
ROOM AND BOARD MAXIMUM BENEFIT LIMIT (MBL) physiological functions of the member (not for cosmetic/aesthetic per year
Regular Private 75,000 / illness / member / year >Ambulance Service shall be covered as follows:
- accredited hospital/clinic to accredited hospital/clinic - up to MBL purposes): > Spondylosis shall be covered up to Php50,000.00 per member per
100,000 / illness / member / year - face warts: up to Php1,000.00 per member per year year
150,000 / illness / member / year - non-accredited hospital/clinic to accredited hospital/clinic - thru
reimbursement up to Php2,500.00 per conduction - neck down (except genital warts and condyloma acuminata): up to > Intellicare shall provide one (1) nurse, Monday to Friday from
200,000 / illness / member / year the maximum benefit limit per year 9:00am to 6:00pm
Note: The ambulance service provided herein shall be available
300,000 / illness / member / year Note: > Valvular heart disease (congenital and/or acquired) including
regardless of the location within the Philippines
PEC COVERAGE (PRE-EXISTING CONDITION) a. Electrocauterization of skin lesions such as plantar warts, flat warts, Cardiomyopathies, Chronic Glomerulonephritis, previous
4. EMERGENCY CARE BENEFITS periungual warts, filiform warts and molluscum contagiosum, in any craniotomy sequelae / hearing impairment / neurologic disease and
All Principals / part of the body, except genital warts and condyloma acuminata, spinal stenosis (if pre-existing) poliomyelitis / slipped disc (if
> Professional services of emergency room physicians
Existing Dependents MBL prescribed by Accredited Physician/Specialist - MBL/member/year pre-existing) and Guillane barre syndrome, diabetes and its
> Medicines administered during treatment or for immediate relief
New Dependents MBL (except cost of vaccines) b. Frequency of visits for repeat cautery: complications (if pre-existing), Complicated hypertension (e.g those
- face and neck - minimum of 6 months from last cauterization with history of stroke, myocardial ischemia or infraction an poor
PROGRAM BENEFITS > Oxygen and intravenous fluids, dressings, plaster casts, and sutures
> Laboratory tests, x-rays, and other diagnostic examinations directly - other sites like extremities, back and abdomen - minimum of 6 kidney function) and all malignant tumors (if pre-existing) shall be
related to the emergency management of the patient months from last cauterization covered up to pre-existing condition limit per member/year.
1. PREVENTIVE HEALTHCARE BENEFITS > Eye laser therapy only for retinal tear, retinal hole, retinal > Maternity Assistance: A maternity assistance program shall be
> Routine immunization (except cost of vaccines) detachment and glaucoma precribed by an Accredited made available to all married and single “female employees” and
> Management of health problems * IF THE MEMBER IS TREATED IN
a. AN ACCREDITED HOSPITAL with an AFFILIATED PHYSICIAN Physician/Specialist shall be covered up to PEC limit per year. Eye “legal spouse” of male employees. The enrolled member may avail
> Record-keeping of medical history correction such as lasik, PRK and the like shall not be covered of the maternity assistance only once per contract period based on
> Medical seminars/wellness programs Patient is covered 100%
b. A NON-ACCREDITED HOSPITAL > Sclerotherapy for varicose veins (except medicines and for actual cost but not to exceed the following limits:
> Annual Physical Examination (for Principals and Dependents) cosmetic purposes) shall be covered up to Php20,000.00 per leg Normal Delivery PHP40,000.00
Intellicare shall reimburse 80% of hospital bills including
professional fees of attending doctors (based on Intellicare’s per member per year provided that it is medically necessary and Caesarean Delivery PHP50,000.00
The Annual Physical Examination (APE) will include: recommended by an affiliated vascular surgeon Miscarriage and abortion PHP30,000.00
Physical examination Relative Value Scale), but not to exceed Php 30,000
c. A FOREIGN TERRITORY > Allergy Testing/allergy screening will be covered up to Php20,000.00 Dilation and Curettage PHP20,000.00
Complete blood count (CBC) per member per year if prescribed by Accredited Physician
Urinalysis Intellicare shall reimburse the member on what should have
been paid had the member been confined in an accredited > Tuberculin Test will be covered up to Php2,000.00 per member per IN-PATIENT CARE
Fecalysis year if the member shows symptoms of Tuberculosis and if ACCESS TO IN-PATIENT CARE
Chest x-ray hospital in the Philippines (based on Intellicare’s relative value
scale), but not to exceed Php 30,000 prescribed by accredited physician * If the room that I am entitled to is fully occupied, could I occupy a higher room
Eye Refraction > Passive and active vaccines for treatment of tetanus and animal
Electrocardiogram (for members 35 years old and above, or if category?
5. DENTAL CARE BENEFITS bites shall be covered up to Php50,000.00 per member per year
indicated by the attending physician) Involuntary Room Upgrading:
> Dental examination > Botox injection shall be covered up to five thousand pesos
Pap smear (for female members 35 years old and above, or if (Php5,000.00) per member per year if recommended by an
> twice a year prophylaxis > If entitled room is not available, member may occupy one (1) category
indicated by the attending physician) accredited/ affiliated physician to be medically necessary (NOT for
> Simple tooth extractions higher (except suite room) without incremental charges for the first 48
> Temporary fillings cases to treat facial nerve paralysis, muscle twitching and other hours.
2. OUT-PATIENT CARE BENEFITS related cases or for aesthetic/beautification purposes)
> Permanent filling up to four (4) teeth per year – If within 48hours the entitled room becomes available, member should
> Any number of medically necessary consultations with any > Reconstructive plastic surgery that is medically necessary as a
> Desensitization of hypersensitive teeth up to two (2) teeth per year transfer automatically to their entitled room category.
Intellicare-affiliated physician (except cost of medicines) direct result of an accident or because of other surgery shall be
> Simple adjustment and repair of dentures – After 48 hours, whether the entitled room becomes available or not,
> Referral to Intellicare-affiliated specialists covered
> Open incision and drainage (intraoral) incremental charges will be charged to the member already.
> Treatment of minor injuries such as lacerations, mild burns, sprains, and > Initial treatment for animal bites except vaccines shall be covered
the like. > Recementation of jackets, crowns, inlays, onlays * If I want to stay in a more expensive room, and am willing to pay for the
> Treatment of minor gum problems, mouth lesions, wounds and burns up to the maximum benefit limit per year for the 1st twenty-four (24)
> Laboratory exams, x-ray, and other diagnostic procedures prescribed by hours from the time the member was bitten accommodation, may I do so?
an Intellicare-affiliated physician. > Orthodontic consultations (for braces and malposition of teeth)
> Temporo mandibular joint consultation (for clicking of jaws) > Work-related cases shall be covered up to the maximum benefit Voluntary Room Upgrading:
> Minor surgery not requiring confinement. limit per principal per year subject to the exclusions and limitations
> Pre- and post-natal consultations up to MBL with any Intellicare-affiliated > Pre-natal check of teeth and gums > Yes. However, keep in mind that staying in a more expensive room also
> Emergency dental treatment for the relief of pain of the contract makes the other services (i.e., medicines, professional fee, etc.) more
OB-GYN (excluding tests) > Motor vehicular accidents shall be covered up to the maximum
> Speech therapy (for stroke patients only) shall be covered through expensive.
6. FINANCIAL ASSISTANCE (for Principal members only) benefit limit per year subject to the exclusions and limitations of the > You will be charged for the excess over your entitlement and should pay
reimbursement up to 12 sessions per member per year contract and a Police report MUST be submitted to Intellicare for
(Note: Consultations considered as session) Death(Amount of insurance) - Php 50,000.00 the excess upon discharge (approximately 30% of your total hospital bill,
Loss of both hands - 100% of amount of insurance evaluation excess room & board and doctor’s fee). All excess bills shall be collected
> Physical therapy/occupational therapy excluding subspecialties such as > Unprovoked murder & assault shall be covered up to the maximum
cardiac rehabilitation, pulmonary rehabilitation and the like shall be Loss of both feet - 100% of amount of insurance from you before discharge.
Loss of one hand and one foot - 100% of amount of insurance benefit limit per year subject to the exclusions and limitations of the
covered up to 36 sessions/member per year; subject to PEC limit for OP contract and a police report must be submitted to Intellicare for
One hand - 50% of amount of insurance
Arm between elbow and wrist - 60% of amount of insurance evaluation
3. HOSPITALIZATION / IN-PATIENT CARE BENEFITS
> Room and Board accommodation within the limits of the plan Arm at or above elbow - 70% of amount of insurance > Scoliosis including necessary procedures, except physical therapy *KINDLY REFER TO SEPARATE PAGE FOR
Leg below knee - 60% of amount of insurance sessions, whether congenital, pre-existing, developmental or
> Professional fees of attending Intellicare-affiliated physicians
> Diagnostic procedures referred by the attending Intellicare-affiliated Leg at or above knee -70% of amount of insurance acquired shall be covered up to the maximum benefit limit per year THE GENERAL EXCLUSIONS & LIMITATIONS
Loss of sight- Both eyes - 100% of amount of insurance (shared limit for OP and IP)
physicians/specialists > Congenital conditions except physical therapy sessions and
> Administered medicines (taken orally or intravenously) - One eye - 50% of amount of insurance
Loss of speech - 100% of amount of insurance developmental disorders shall be covered up to Php100,000.00 per
> Transfusion of blood (including whole blood products) and intravenous member per year (shared limit for OP and IP); subject to PEC limit
fluids Loss of hearing- Both ears - 100% of amount of insurance
- One ear - 50% of amount of insurance (whichever is lesser) while congenital hernia shall be covered up to
> Anesthesia and its administration PEC limit
> Use of the Operating Room and Recovery Room facilities Accidental Dismemberment or Loss of Use of Fingers
- All of one hand - 50% of amount of insurance > Chronic dermatoses shall be covered for consultations and
> Use of the Intensive Care Unit (ICU) treatments per year
> Standard nursing care services, standard admission kit sutures, > Scabies shall be covered for consultations and treatments per year
dressings, plaster, casts, and other items directly related to the