FREQUENTLY ASKED QUESTIONS

What if ValuCare Coordinators are not available in an accredited hospital during regular clinic hours, what shall the plan holder do?

If emergency, proceed directly to emergency room or call

ValuCare Customer Service Hotline (02-702-3310) for immediate endorsement to emergency room personnel. If non-emergency, call ValuCare Customer Service Hotline (02-702-3310) for the following assistance:

• ValuCarewill endorse plan holder to appropriate accredited doctor within the hospital.

• ValuCarewill provide other necessary documents as required by accredited hospital.

• ValuCarewill refer member to nearest accredited clinic/hospital if no appropriate accredited doctor available within the hospital.

Plan-holder seek medical consultation or outpatient healthcare services on accredited hospital during Sundays, will the member be accommodated?

There are no available doctors in the hospital for out-patient healthcare services during Sundays except those in emergency room (even on Saturdays, most doctors are on half-day schedule). Call ValuCare Customer Service Hotline (02-702-3310) for assistance.

• ValuCare will refer Planholder to the nearest accredited clinic.

• Doctors on our accredited clinics are available during Sundays,especially those inside malls. They have doctors with different specializations which make them ideal provider for out-patient healthcare service (non-emergency) during weekend; being inside the mall is also an added convenience.

On in-patient case, the hospital is accredited but the doctor attended the case is not accredited, what will be ValuCare's coverage?

• The case will not be covered since it is included in the Exclusions & Limitations: Service from Non- ValuCare Accredited Physicians and / or Non- ValuCare Accredited Hospitals and other health / medical providers, including adverse medical conditions arising from treatment of the same except those stipulated under the provisions on emergency care services.

• If client has Point of Service provision, the applicable expenses will be reimbursed following ValuCare reimbursement procedures.

• If ValuCare does not have accredited specialist doctor appropriate for the member’s case within the accredited hospital, hospital bills will be covered by ValuCare and Professional Fee will be on a reimbursement basis (subject to MCB, Exclusions & Limitations, and ValuCare reimbursement procedures).

• The case will not be covered since it is included in the Exclusions & Limitations: Service from Non- ValuCare Accredited Physicians and / or Non- ValuCare Accredited Hospitals and other health / medical providers, including adverse medical conditions arising from treatment of the same except those stipulated under the provisions on emergency care services.

• If client has Point of Service provision, the applicable expenses will be reimbursed following ValuCare reimbursement procedures.

• If ValuCare does not have accredited specialist doctor appropriate for the member’s case within the accredited hospital, hospital bills will be covered by ValuCare and Professional Fee will be on a reimbursement basis (subject to MCB, Exclusions & Limitations, and ValuCare reimbursement procedures).

Upon availing, the hospital is not accredited but the doctor attended is accredited, what will be our coverage?

• Call ValuCare Customer Service Hotline (02-702-3310) for assistance in transferring to accredited hospital, if medically possible (for admitted case).

• If case is an emergency, ValuCare will reimburse it subject to pre-existing condition coverage, exclusions & limitations, and reimbursement procedures of ValuCare .

• If non-emergency, ValuCare will not cover the case.

Upon availing, member has no coverage or has exhausted coverage for Pre-Existing Conditions (PEC) and the diagnosis has not been established, will the member be accommodated?

• For confinement, ValuCare Hospital Liaison Officer will visit admitted member for assistance within 24 hours of confinement (contact member if in provincial areas) to explain nature of the case. ValuCare coverage is based on the diagnosis given by the accredited doctor.

• ValuCare will not cover the case until no established diagnosis has been given by the attending accredited doctor.

• If the confinement has been paid by the member. But, the final diagnosis can be covered by the program; ValueCare will reimburse 100% of applicable hospital bills androfessional fees based on ValuCare Relative Value Unit and subject to ValuCare reimbursement procedures.

For In-patient case, a member admitted under ValuCare prefers his family/personal doctor to manage his care, what will be ValuCare's resolution?

• Value Care as much as possible, will advise the member that it is not appropriate on medical practice to have two doctors of same specialty managing his case at the same time.

• If member insists, he has to pay the professional fee of the non-accredited doctor.

• ValuCare will only cover prescriptions made by the accredited doctor.

Upon availing, accredited provider did not honor VC Card & decline accommodation

• Immediately call ValuCare Customer Service Hotline (02-702-3310) for assistance.

• ValuCare Customer Service will ask for the nature of the member’ case. If case can be covered by the program, ValuCare customer representative will call the provider to endorse immediate accommodation of the member.

• For reasons outside the member’ program, ValuCare upon receiving the complaint will immediately investigate the case through proper coordination with the accredited provider involve. Also provide feedback and/or resolution to member may it be in a verbal or written form as case requires.

If a member wants to know his present remaining Maximum Coverage Benefit (MCB) what will he do?

• Contact ValuCare Customer Service Hotline (02-702-3310) or account officer-in-charge and request for your updated MCB computation.

• ValuCare customer service representative or account officer-in-charge, after proper verification, will revert to client the requested information.

If a member, (child or adult) is suspected or manifesting signs and symptoms of dengue illness but apparently, ValuCare Coordinator demands that the case can still be managed on outpatient basis, can member insist to be admitted?

• ValuCare Coordinator will base his professional advice depending on the results of laboratory tests requested to diagnose the illness of the member. Since ValuCare coverage is based on diagnosis and prescriptions best advised by accredited doctors, member must follow accredited doctor’ order to manage the case on out-patient basis for continuous coverage by ValuCare.

• General Exclusions & Limitations Article 6.5 Refusal to Comply with Treatment ValuCare shall have no obligation to continue providing health care coverage to Planholders who refuse to comply with any treatment or procedure recommended by a ValuCare Health Professional.(ValuCare is also under no obligation to continue providing health care coverage to Planholders who refuse to be discharged from confinement after his/her attending ValuCare Health Professional has recommended the discharge.)

What if surgical procedure is covered but during operation, another surgical procedure was included and done the same time as medically advised by surgeon. What will be ValuCare's coverage and computation on Professional Fees and hospital charges?

• ValuCare will coordinate with the hospital and secure Operative Records for proper evaluation.

• If 2nd Procedure is not covered, ValuCare after proper evaluation of operative records will only cover all that pertains to the coverable procedure.Everything that is related with the other non-covered procedure will be paid by the member to the hospital upon discharge. If 2nd Procedure is covered, only Professional Fee will be considered as separate MCB.The 2nd procedure will share MCB on first as stated on *SPECIAL PROCEDURES* The limits stated on medical modalities & special procedures are subject to MCB, Pre-Existing Conditions provisions, Exclusions & Limitations and antecedent expenses.The limit for procedures that may require confinement shall be inclusive of room & board, operating room charges, professional fees, and other incidental expenses relative to the procedures.

If VC Card is not available or has not been brought by member during availing, what will he do?

• Immediately call ValuCare Customer Service (if possible) and ask for assistance or your membership code.

• Clearly declare status of your ValuCare membership to ValuCare Plan Coordinator and present any valid ID (present membership code if available) for verification.

• For emergency case, proceed directly to emergency room and declare you’re a member of ValuCare. Emergency room personnel will call ValuCare Customer Service Hotline to verify your membership with ValuCare.

If member has applicable government subsidized discounts, will it be deducted on the Maximum Coverage Benefit (MCB)?

• Applicable discounts will not be deducted from the Maximum Coverage Benefit computation.

• Members are encouraged to avail discounts to maximize usage of their Maximum Coverage Benefit (MCB).

What if accredited doctor is requesting for additional /extra charge on Professional Fee of a procedure or treatment being covered by ValuCare?

• Immediately contact ValuCare Customer Service Hotline (02-702-3310) for assistance.

• ValuCare Accredited Providers must not asked for payment from member for services that are covered by the program except:

1. Member avail a higher room & board than his plan,

2. On exceptional case wherein member approved and coordinated with ValuCare Office.

• Members must not make pre-arrangements of payment with accredited doctors. Any agreement of payment made by the member with the attending accredited doctor before ValuCare‘ knowledge will not be Value Care’ liability.

If member' running bill exceeds MCB, can member choose which to be covered by ValuCare whether Professional Fees or hospital bills?

• Member may choose either since coverage of ValuCare is all-in for hospital bills and professional fees. However, it is recommended to allot ValuCare coverage to professional fees given that it’ already negotiated rates based on Relative Value Units (to avoid charging of higher Professional Fees by doctors).

After a motorcycle accident with a third party involve, the member was the injured party but according to Police Report, the member was the one at fault. Will ValuCare cover/reimburse the case after filing Deed of Subrogation?

• ValuCare will only cover Motor Vehicular Accidents if Police Report indicates that member is not at fault (member must file Deed of Subrogation)

What if member has two health cards or medical coverage, can the member use two coverage at the same confinement?

• Dual coverage/double indemnity is not allowed by the program. Member must choose only one card to be used per confinement.

Are all members entitled to Executive Check-up (ECU)? Is there a difference between Executive Check-up and Annual Physical Exam (APE)? What are the differences between the two?

• Not all members are entitled to executive check-up.Unless the members has this provision.

• Yes, Executive Check-up varies from Annual Physical Check Exam:

1.Annual Physical Exam (APE) is a yearly basic preventive medical routine compose of doctors assessment base on the medical history, complete blood count, chest X-ray, urine exam, stool exam, electrocardiogram (ECG) & pap smear for 35 years old and above, while,Executive Check-up (ECU) has more numerous & extensive sets of medical procedures usually covering all body systems.

2.Annual Physical Exam is done in an accredited clinic (few cases scheduled in accredited hospital if no accredited clinic is nearest within particular area in province) while Executive Check-up is done in an accredited hospital.Both APE and ECU are scheduled.

In operations where skin grafting is required as a part of the medical treatment, would ValuCare cover the cost of the procedure?

• If it is deemed necessary by the attending accredited doctor and the case does not fall under Exclusions and Limitations, ValuCare will cover the procedure subject to program’ coverage of diagnosis.

If vaccination is the only treatment for an emergency case would ValuCare cover the cost of the vaccines (e.g. snake bites, anti-rabies)? Does the exclusion only apply to ""preventive"" vaccines?

• It is part of Program’ Exclusions & Limitations that no health care benefits shall be paid for (x) Vaccines, Screening Test, allergy including desensitization tests and treatment materials.

• Cost of vaccines (eg. anti-venom, anti-rabies) will be covered if included in the program. If it is not included in the program, neither preventive nor emergency cases will not be paid by ValuCare (only the administration of vaccine will be covered).

Are there any limitations on X -RAY coverage?

• Actual cost of X-ray is covered by the program subject to Maximum Coverage Benefit (MCB), Pre-Existing Condition (PEC) Coverage, and Exclusions & Limitations.

If the member was misinformed about the reimbursement process from an accredited doctor' office who will be held liable?

• ValuCare is the best authority to contact for its accurate reimbursement procedures and correct information on member’ program. ValuCare Plan Coordinator and Accredited Doctors were accredited primarily to provide quality healthcare to member and not trained for internal procedures of ValuCare Office.

• ValuCare will not be held liable for misinformation caused by it’ accredited providers nor any party not employed by ValuCare.

• General Exclusions & Limitations � 6.4 No Liability ValuCare shall not be liable for any defaults, failures to assist, or delays in the delivery of services herein provided which are due to causes beyond its control, including, but not limited to,acts or any order of government, fires, floods, epidemics, complete or partial destruction of hospital or medical facilities, civil disturbances, strikes and other labor disputes, unduly severe weather, or incidents of war. ValuCare shall, however,continue to exert its best efforts to provide health care services to the Member insofar as circumstances will allow.

If a case were not clearly specified in the exclusions list under the statement of benefits, would ValuCare reimburse payment for the medical service if the policyholder had to pay initially?

• ValuCare will only reimburse medical expenses paid by the member during emergency base on the member’ plan. Also on condition that the case is not included in the list of exclusion and limitations.

If the visit to the ER resulted to an incomplete diagnosis and requires multiple visits to the hospital, would the policy holder need to pay for the medical expenses until a complete diagnosis is provided by the physician?

• ValuCare base its coverage on the diagnosis given by the attending accredited doctor. If there’ no diagnosis yet established, ValuCare will not cover the case.

• The member may file for reimbursement once diagnosis has been given and and the case can be covered the program (ValuCare reimbursement procedures apply).

What is the reimbursement procedure for disputed claims that was previously declined? Is there a cut-off time for this?

• ValuCare will provide notice for disapproved reimbursement claim. The member must then submit a letter of appeal within 7 days from receipt of notice stating the reasons including any documents to justify his claim.

• ValuCare will then re-evaluate the petition and provide feedback within 15 working days upon receipt of such.

• Member has 30 days, if case is within Metro Manila (60 days if provincial), from date of discharge to file for reimbursement. Filing reimbursement after prescribe period will invalidate the claim.

What if the hospital has a cash basis policy for some of the procedures even if they are recommended by an accredited doctor?

• If it is the policy of the accredited hospital that certain procedures must be on cash basis, then member may opt to choose:

   1.Avail the procedure in same hospital and pay cost of procedures as required by hospital.

   2.Call ValuCare Customer Service Hotline (02-702-3310) for endorsement to other nearest accredited clinic or accredited hospital that allows outright HMO coverage for such procedures.

   3.General Exclusions & Limitations Article 6.6 Hospital Policy states: Hospital care services shall be subject to the rules and regulations of the Accredited Hospital.

Is it true that I need to pay for the professional fees of accredited Neurologist, EENT and Urologists? If there is a recommended procedure, should I also pay for the cost?

• Call ValuCare Customer Service Hotline (02-702-3310) for assistance.

• Normaly, Neurologists practicing in Philippines do not accept accreditation from HMO provider. But ValuCare Customer Service representative, as much as possible, will seek arrangements with our partnered Neurologists for coverage of member’ case.

• ValuCare has accredited EENT and Urologist wherein cases under their management will be covered by ValuCare Program

Who determines the hospital visit as emergency?

• The attending doctor determines whether case is an emergency or not. ValuCare Health Service Agreement defines Emergency Condition as a life threatening or serious accidental injury of a sudden and unexpected onset of a condition which at time of the occurrence reasonably appears to have the potential of causing immediate disability or death.These illnesses or injuries require urgent medical or surgical care which the Planholder secures immediately after the onset.

FREQUENTLY ASKED QUESTIONS

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