TRAINING GUIDE

HMO - stands for Health Maintenance Organization is a healthcare delivery system that most employees are entitled to use as part of the benefit they receive from their employers.

TPA - stands for Third Party Administrator and as such is defined as an organization or individual that handles the claims, processing, and reporting components of a self-funded health benefits plan.  

MBL - stands for  maximum benefit limit refers to the consumable limit one can use per treatment/illnesses, per person, per year. 

ABL - stands for annual benefit limit refers to the maximum aggregate limit in availing applicable benefits and services limited to covered illnesses on a per member per year or per family unit per year basis as may be applicable. 

INNER LIMIT - refers to a specific cap or limit on certain types of coverage, often within a broader or more general policy limit. Essentially, the "inner limit" is a sub-limit or a restrained cap placed on specific medical treatments, procedures, or services, even if the overall coverage limit (the total sum the insurer will pay) is higher.

UTILIZATION - refers to the use or consumption of healthcare services by policyholders or beneficiaries. It essentially measures how often and to what extent people are utilizing the benefits and services provided under their health insurance plan.

EXCLUSION or UNCOVERED ITEMS - refers to specific conditions, treatments, or situations that are not covered by an insurance policy. These are exceptions where the insurer will not provide financial coverage or reimburse costs, even if the condition or treatment is medically necessary. Exclusions are typically listed in the policy document and are an important part of the terms and conditions of the insurance contract.

PEC - stands for preexisting condition is a term that refers to a known illness, injury, or health condition that existed before someone enrolls in or begins receiving health or life insurance.

DREADED CONDITIONS - This corresponds to any condition that is considered to be chronic, progressive, life-threatening and which may entail lifelong therapy 

ACCREDITED - (of a person, organization, or course of study) officially recognized or authorized.

NON-ACCREDITED - not recognized as meeting prescribed standards or requirements

UMBRELLA ACCREDITATION - refers to the process where a health insurance company recognizes the accreditation of a hospital system or healthcare network as a whole, rather than accrediting each individual hospital or facility within that network separately.

NON-UMBRELLA ACCREDITATION - refers to a situation where each individual hospital or healthcare facility within a hospital network is separately accredited by a recognized accrediting body, rather than having a blanket accreditation for the entire system (as in umbrella accreditation). In this case, the health insurance company must evaluate and verify the accreditation status of each hospital or facility independently, to ensure they meet the insurer's standards for inclusion in their provider network.

PROVIDER - healthcare providers - clinic and hospitals.

LOA - stands for Letter of Authorization is a letter that authorizes an Amaphil member to avail their needed medical availment in the accredited healthcare partner of Amaphil.

SOB - stands for Schedule Of Benefits is a list of the various services covered under a health insurance plan 

ICD CODE - stands for International Classification of Diseases codes are a set of designations used by healthcare staff to communicate diseases, symptoms, abnormal findings, and other elements of a patient's diagnosis in a way that is universally accepted by those in the medical and insurance fields.

CPT CODE - stands for Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. 

RUV CODE - stands for Relative Value Unit a number assigned to compensable services provided by a physician.

RVS CODE - stands for  relative value scale is a key element in the construction of a physician fee 

OUTPATIENT BASIC CONSULTATION and OUTPATIENT-REFERRAL-TO-SPECIALIST

Medical consultation refers to a meeting or interaction between a patient and a healthcare provider (typically a doctor, specialist, or other medical professional) in order to evaluate, diagnose, and provide treatment recommendations for the patient’s health concerns. It is a key component of the healthcare process and can take place in various settings such as a clinic, hospital, or through telemedicine.

OUTPATIENT CLINIC-SETTING and OUTPATIENT-LABORATORY

Clinic-setting procedures are minor medical procedures may be performed directly in the clinic. These procedures often involve basic or non-invasive treatments.

Laboratory tests are a critical part of the diagnostic process in healthcare. These tests help healthcare providers assess a patient’s health, diagnose conditions, monitor ongoing treatments, and detect diseases early. They are often used to measure various substances in a patient’s blood, urine, or other bodily fluids to gain insights into the function of organs and overall health status.

Imaging tests are medical procedures that use various technologies to create visual representations of the interior of the body. These tests are crucial for diagnosing, monitoring, and guiding treatment for various medical conditions. They help healthcare providers see structures inside the body, detect abnormalities, and assess the progress of diseases. Imaging tests are non-invasive (except for some specific types) and provide a clear view of tissues, bones, organs, and vessels, assisting in precise diagnosis and treatment planning.

EMERGENCY (ER)

Emergency care typically falls under a category called "Emergency Medical Services" or "Emergency Care" availment. This refers to immediate medical attention for severe or life-threatening conditions that require prompt treatment to prevent serious harm, disability, or death.

OUT-PATIENT SURGERY (OPD-OR)

The term "OP or" in a medical context typically refers to "Outpatient Operating Room" or "Outpatient Surgery". It is used in settings where surgeries or procedures are performed on patients who do not require an overnight stay in the hospital. The patient comes in for the procedure and leaves the same day.

IN-PATIENT ADMISSION AND DISCHARGE

Inpatient admission refers to the process of a patient being formally admitted to a hospital or medical facility for treatment, where they are required to stay overnight or for a longer duration. This type of admission is necessary when a patient requires intensive care, monitoring, or a surgical procedure that needs more than just a brief visit or outpatient care.

Inpatient discharge refers to the process in which a patient is formally released from the hospital after being admitted for care. It occurs when the patient no longer requires inpatient care, has recovered sufficiently, or is stable enough to continue recovery at home or in a less intensive care setting (such as a rehabilitation facility or long-term care facility). The discharge process involves several steps to ensure that the patient’s medical, emotional, and logistical needs are met for the next phase of recovery.

UNLESS EXCEPTIONS TO THE FOLLOWING GENERAL EXCLUSIONS ARE MADE UNDER THE BENEFITS PROVISIONS, THIS PROGRAM DOES NOT COVER ANY LOSS CAUSED BY OR RESULTING FROM ANY OF THE FOLLOWING:

1.  Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or government licensing, health permit and other similar purposes.

2.  Custodial, Domiciliary, Convalescent and Intermediate care

3.  Professional fees of medico-legal officer/s. Medico-Legal Fees.  These are professiAonal fees of a medico-legal consultant to whom a patient is referred primarily for the issuance of a medical certificate for legal purposes.

4.  All   expenses incurred in the process of organ donation and   transplantation if the   Member is the donor, and its complications.

5.  Benefits covered by Phil health and all other government funded healthcare entitlements as provided for by law.

6.  Purchase or lease of any Durable Medical Equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.

7.  All pregnancy related conditions requiring medical and surgical care.

8.  Circumcision (except treatment of urological conditions), sterilization of either sex or reversal of such, artificial insemination, sex transformation or diagnosis and treatment of infertility.

9.  Cosmetic procedure and surgery and oral surgery solely for purpose of beautification, including but not limited to wart removals through excision or electrodessication/ cauterization except reconstructive surgery to treat functional defects due to disease or accidental injury.

10.   Weight reduction programs, surgical operation or procedure for treatment of obesity, including but not limited to gastric stapling.

11.   Dental care following accidental injury to teeth requiring reconstructive surgery, orthodontic   procedures or supply of dentures.

12.   Long term rehabilitation and all forms of behavioral disorders whether congenital or acquired; developmental or psychiatric disorder; psychosomatic illness.

13.   Any injury, illness or condition which the Member may suffer after he has taken intoxicating drugs or alcoholic beverage as evidenced by clinical history or alcoholic breath as determined by the examining physician and/or conditions or illnesses resulting from Alcoholism and Drug Addiction.

14.   Medical or surgical procedures that are experimental in nature and not generally accepted as standard medical treatment by the medical profession that may include but is not limited to, Chiropractic Services and Acupuncture.

15.   Allergens used for hypersensitivity testing regardless if administered as an out-patient or in-patient procedure.

16.   Injuries or illnesses resulting from hazardous activities in which a Member has engaged in leisure that may include but is not limited to:  bungee jumping, scuba diving, hang-gliding, mountain climbing and all such other voluntary activities which pose a danger to life and limb, except those related to or directly connected with the Member’s occupation as declared in the application for health care coverage under the Agreement.

17.   Injuries or illnesses due to military service or suffered under conditions of war.

18.   Executive check-ups and confinement which are for purely diagnostic purposes except as specified in the Agreement.

19.   Injuries or illnesses which are self-inflicted, caused by attempt at suicide, or incurred as a result of or while participating in the commission of a crime or acts involving the violation of laws or ordinances.

20.   Take-home medicine, immunizing agents and out-patient medicines, with the exception of intravenous chemotherapy medicine and those administered during an emergency treatment.

21.   Vaccines, whether elective or administered during an emergency treatment are not covered, except passive and active vaccine for anti-tetanus, anti-venom, and anti-rabies vaccine as specified in the Agreement.

22.   Laser Treatment for the purpose of corrective eye refraction.

23.   Sexually transmitted diseases, AIDS and AIDS related diseases.

24.   Congenital deformities and abnormalities unless specified in this Agreement.

25.   Infectious diseases (according to the local epidemiological patterns) that may arise in times of an epidemic (i.e. Avian Flu, Meningococcemia, etc.) as declared by World Health Organization (WHO) and/or by Department of Health (DOH).

26.   Dietary consultations, weight reduction programs, surgical operation or procedure for weight reduction, treatment of obesity, including gastric stapling or balloon procedures and liposuction.

OUTPATIENT BASIC CONSULTATION and OUTPATIENT-REFERRAL-TO-SPECIALIST:

• NAME OF CALLER

• PROVIDER’S NAME

• TYPE OF AVAILMENT

• COMPLETE NAME OF THE PATIENT / CARD NUMBER OF THE PATIENT

• COMPANY NAME

• VALID ID PRESENTED (IF AMAPHIL CARD PRESENTED ONLY ASK FOR DOB)

• CHIEF COMPLAINT

• NAME OF THE CONSULTING DOCTOR / SPECIALIZATION (CHIEF COMPLAINT SHOULD BE ALIGNED WITH THE DOCTOR'S SPECIALIZATION, OTHERWISE, VERIFICATION IS REQUIRED)

OUTPATIENT CLINIC-SETTING and OUTPATIENT-LABORATORY:

• NAME OF CALLER

• PROVIDER’S NAME

• TYPE OF AVAILMENT

• COMPLETE NAME OF THE PATIENT / CARD NUMBER OF THE PATIENT

• COMPANY NAME

• VALID ID PRESENTED (IF AMAPHIL CARD PRESENTED ONLY ASK FOR DOB)

• GIVEN DIAGNOSIS

•  PROCEDURES - OP-LAB  (FOR THE EXACT AMOUNT OF EACH PROCEDURE, HOWEVER, IF THE LOA REQUEST IS MADE THROUGH THE AMAPHIL MOBILE APP , VIA EMAIL FROM THE MEMBER, OR THROUGH THE VIBER GCs WITH OUR CORP ACCOUNTS, THERE IS NO NEED TO REQUEST THE EXACT AMOUNT, AS IT WILL BE BASED ON SLMC RATES.)

• PROCEDURES - OP-CLINIC-SETTING (VERIFY IF THIS FALLS UNDER A CLINIC SETTING. IF IT DOES, KINDLY CONFIRM WHETHER THEY HAVE THEIR OWN RATE OR IF THE AMAPHIL RATE WILL BE APPLIED)

EMERGENCY:

• NAME OF CALLER

• PROVIDER’S NAME

• TYPE OF AVAILMENT

• COMPLETE NAME OF THE PATIENT / CARD NUMBER OF THE PATIENT

• COMPANY NAME

• VALID ID PRESENTED (IF AMAPHIL CARD PRESENTED ONLY ASK FOR DOB)

• CHIEF COMPLAINT

• GIVEN DIAGNOSIS

• PROCEDURES (REQUEST FOR A COPY OF THE FINAL ITEMIZED CHARGES)

NOTE:

Charges must be final. If not yet available, only an initial limit may be provided. Remind the provider that final coverage and approval will be based on the final diagnosis.

For ER cases, if final billing is already available please request the provider to send the itemized billing thru email or viber (AMY), instead of getting the charges through verbal call to avoid long duration of calls

OUT-PATIENT SURGERY (OPD-OR):

• NAME OF CALLER

• PROVIDER’S NAME

• TYPE OF AVAILMENT

• COMPLETE NAME OF THE PATIENT / CARD NUMBER OF THE PATIENT

• COMPANY NAME

• VALID ID PRESENTED (IF AMAPHIL CARD PRESENTED ONLY ASK FOR DOB)

• GIVEN DIAGNOSIS

• PROCEDURE  (ESTIMATE AMOUNT NET OF PHIC)

• RVS CODE (WE WILL ISSUE LOA FOR THE HB ONLY IF NO RVS CODE PROVIDED)

• SURGEON’S NAME (ASK IF ACCEPTING)

• ANESTH’S NAME (ASK IF ACCEPTING) (IF APPLICABLE)

IN-PATIENT ADMISSION:

ER LEADING TO CONFINEMENT:

• NAME OF CALLER

• PROVIDER’S NAME

• TYPE OF AVAILMENT

• COMPLETE NAME OF THE PATIENT / CARD NUMBER OF THE PATIENT

• COMPANY NAME

• VALID ID PRESENTED (IF AMAPHIL CARD PRESENTED ONLY ASK FOR DOB)

• CONTACT NUMBER OF THE PATIENT/GUARDIAN

• ASK IF ER LEADING TO CONFINEMENT/DIRECT ADMISSION

• CHIEF COMPLAINT

• ADMITTING DIAGNOSIS

• ATTENDING PHYSICIAN/SPECIALIZATION (ASK IF ACCEPTING AMAPHIL)

• ASK IF THERE ARE OTHER PHYSICIANS

• ROOM AVAILED

• IF CASE IS ACCIDENT ASK FOR IR/POLICE REPORT

DIRECT/ELECTIVE ADMISSION:

• NAME OF CALLER

• PROVIDER’S NAME

• TYPE OF AVAILMENT

• COMPLETE NAME OF THE PATIENT / CARD NUMBER OF THE PATIENT

• COMPANY NAME

• VALID ID PRESENTED (IF AMAPHIL CARD PRESENTED ONLY ASK FOR DOB)

• CONTACT NUMBER OF THE PATIENT/GUARDIAN

• ASK IF ER LEADING TO CONFINEMENT/DIRECT ADMISSION

• ADMITTING DIAGNOSIS

• PROCEDURE/SURGERY TO BE DONE

• SURGEON'S NAME (ASK IF ACCEPTING AMAPHIL)

• ANESTHESIOLOGIST  (ASK IF ACCEPTING AMAPHIL)

• ASK IF THERE ARE OTHER PHYSICIANS

• ROOM AVAILED

• IF CASE IS ACCIDENT ASK FOR IR/POLICE REPORT

To Provider: 

INITIAL LIMIT OF THE MEMBER (at least 50% of the patient’s ABL/MBL, excluding FirstLife accounts, as they requested that we provide the facility with the patient’s maximum MBL) - 

ROOM ENTITLEMENT (RBE & INCREMENTAL IF APPLICABLE)

REQUIREMENTS (REQUIRED TO FILE PHIC/CORP SPECIAL INSTRUCTIONS)

UNCOVERED ITEMS (BRIEF ONLY): MISCELLANEOUS FEEs & PERSONAL ITEMS LIKE PILLOWS, LINENS, FOODS/SNACKS, VITAMINS, TAKE HOME MEDICINES

ASK THE PROVIDER IF THEY HAVE OTHER QUESTIONS ASIDE FROM WHAT WAS DISCUSSED

INFORM THEM THAT IF THEY HAVE FURTHER INQUIRIES/QUESTIONS JUST CALL US IN OUR HOTLINE OR MAY EMAIL US AT mo@amaphil.com.ph

To Patient: 

MAXIMUM LIMIT (Explain to the member regarding the initial limit relayed to the provider)

ROOM ENTITLEMENT (RBE & INCREMENTAL IF APPLICABLE)

REQUIREMENTS (REQUIRED TO FILE PHIC/CORP SPECIAL INSTRUCTIONS)

UNCOVERED ITEMS (BRIEF ONLY): MISCELLANEOUS FEEs & PERSONAL ITEMS LIKE PILLOWS, LINENS, FOODS/SNACKS, VITAMINS, TAKE HOME MEDICINES

NIO (Name of Incident)

TOI (Time of Incident)

POI (Place of Incident)

DOI (Date of Incident)

[Let the patient write everything that had happened before and after the incident and indicate if police intervened during the accident. Indicate also if the patient requested for a medicolegal documentation or certification.]

RATIONALE: This a DOH mandated documentation that needs to be requested from the patient, family member or significant other.