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PMCARE SDN BHD

TERMS AND CONDITIONS

FOR PMCARE – TNB CLOSED PANEL OF

GENERAL PRACTITIONER CLINICS

APPENDIX I

PMCARE SDN BHD TERMS AND CONDITIONS FOR

PMCARE – TNB CLOSED PANEL OF GP CLINICS

Effective Date: 29/07/08, Revision 1 1

1.0 PANELSHIP

Your clinic shall be appointed to our PMCare Sdn Bhd - TNB Closed Panel. 2.0 PRINCIPAL DOCTOR

The Principal doctor for this appointment is Dr Naharudin. 3.0 CLINIC NAME

The offer for the appointment is for Klinik Mesra, hereafter referred to as the clinic. 4.0 CLINIC ADDRESS

Your clinic business address is: No.5231-f Jalan Hamzah 15050 Kota Bahru KELANTAN Under the panelship, you are only authorized to conduct business at the abovestated address. The address shall also be considered as your official correspondence address where all correspondences or notices shall be addressed.

5.0 CLINIC CODE

Your clinic code is D1092 The clinic code is exclusive to the appointed clinic and cannot be used to represent any other clinic, branch or affiliated clinic. Please quote the clinic code in all your correspondences with us including claims submissions.

6.0 MODE OF OPERATIONS

You shall conduct business through the Internet based PMCare Mediline System.

As a PMCare - TNB Closed Panel clinic, you are required to have Internet ready to enable you to implement our Mediline system applications before commencement of the panelship.

7.0 CLINIC IDENTIFICATION

To facilitate our corporate clients’ employees and eligible dependents (“Members”) access to your clinic, you are required to display PMCare – TNB Closed Panel of GP Clinics sticker at a prominent place in front of your clinic.




8.0 PROVISION OF SERVICES – MEDICAL ATTENTION, TREATMENT AND ANCILLIARIES

TO PMCARE MEMBERS

You shall provide services only to valid PMCare – TNB Members. Kindly render your services to our Members to the best of your ability and in accordance to your professional code of ethics. Be guided by your terms of appointment, working guidelines, exclusions and the limitations of Member’s benefits under PMCare – TNB program.

9.0 MAINTENANCE OF RECORDS AND CONSENT

Your clinic shall maintain record of every PMCare – TNB Member seen and treated at your clinic and obtain consent for the release of medical information for each visit by requesting the Member or the guardian (for minor) to sign a note of consent. We reserve the right to review the abovestated clinic records for verification of claims. Your clinic shall provide to us on site review and / or submit to us copy of records for verification purpose.

10.0 EXCLUSION

Members’ medical benefits coverage under PMCare – TNB Healthcare Management Services Program is subjected to exclusions. These items are not covered or payable. Kindly refer to Working Guidelines for PMCare – TNB Closed Panel of GP Clinics (List of Exclusion Items – Chapter 2)

11.0 CHARGES

Your charges for the services provided to our Members shall be guided by the agreed schedule of fees under the panelship appointment and Malaysian Medical Association (MMA) schedule of fees.

12.0 MEDILINE CLAIMS SUBMISSION

12.1 Deadline for Claims Submission

Your clinic is required to submit to us your Mediline GP claims within 14 days of date of service provided to our Member. Claim that is submitted late shall not be accepted or payable. For some services, you are required to fax the following document(s) to Claims Dept, PMCare Sdn Bhd immediately upon claim submission through Mediline (if applicable): i) Medical or Laboratory Report ii) HR approval letter for Public Service Vehicle (PSV) License medical checkup iii) HR approval letter for Pre-employment medical checkup iv) HR approval letter for Good Driving License (GDL) medical checkup

For easy reference and to expedite claim processing, you are advised to indicate the AC Code on the documents prior faxing to Claims Dept, PMCare Sdn Bhd.




12.2 Mediline GP Invoicing Listing

You shall invoice PMCare for the services provided to our Members using PMCare Mediline GP Invoicing Listing, duly signed by your authorized personnel and affixed with your clinic’s stamp.

12.3 Submission of Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan

TNB

Clinic must submit Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB on monthly basis. Please separate the forms between TNB Employee and TNB Retiree as per GP Invoicing Listing.

13.0 QUERIED CLAIMS PMCare reserves the right to query your claims for:

i. Exceptionally high charges as compared to industry benchmarks; ii. Questionable or inappropriate prescription or procedure, with given diagnosis and / or

claims for exclusion items.

You will be required to respond to our queries timely i.e. within 1 day for telephone query or 7 days from date of letter for written query. Failure of which the queried amount will be automatically deducted.

14.0 GP CLAIMS SETTLEMENT

PMCare shall accept and process your claims for reimbursement that are complete and timely as per Clause 12.0. We shall pay the accepted claims within 60 days of receipt, except for the following items: i. Treatment provided to non-valid member; ii. Exclusion items; and iii. Medical examination conducted without proper authorization; iv. Claims queried by PMCare.

The payment for queried claims shall be made within 60 days after the queries had been satisfactorily responded and rectified by your clinic. Items (i) to (ii) shall not be payable.

15.0 MODE OF PAYMENT

Payments to your clinic shall be made through our Inter-Bank Giro (IBG) payment system or any other electronic banking payment system, which we may introduce from time to time.

16.0 UNINTERRUPTED SERVICE

You shall provide uninterrupted service to our Members except for period of temporary suspension of service (see Clause 17.0). You shall not deny medical attention to our Members or collect cash for services covered under PMCare Healthcare Management Services Program.




PMCare views rejection of Members and collection of cash from Members for items covered by PMCare Healthcare Management Services Program very seriously and reserves the right to terminate any panel clinic that does so.

17.0 TEMPORARY SUSPENSION OF SERVICE

Both the clinic and PMCare may suspend the panelship appointment for a temporary period of time by giving either party thirty (30) days written notice before the suspension.

18.0 PROVISION OF SERVICES FOR UNCOVERED ITEMS

At your discretion, your clinic may provide services to our Members for items not covered under PMCare – TNB Healthcare Program and you shall collect the fee for the service from the Member strictly on Doctor to Patient basis. However, you shall take due care to explain to the Members of this Clause in order not to prejudice the business arrangement of the panelship.

19.0 CONFIDENTIALITY

All medical records of Members shall be kept strictly confidential and shall not be released to any third party except to PMCare where consent for release of information had been obtained from the Member. Both your clinic and PMCare shall also keep all information in relation to the business arrangement under the panelship strictly confidential.

20.0 CHANGE IN PRINCIPAL DOCTOR, CLINIC OWNERSHIP, CLINIC NAME AND

BUSINESS ADDRESS When there is any change in the principal doctor, ownership or major shareholder of clinic, and/or business address, you are required to inform PMCare in writing one (1) month in advance of the intended change requesting for our approval of the change. PMCare reserves the right to terminate the appointment if for any reason PMCare finds the intended change is unsuitable.

21.0 CHANGE IN OPERATING HOURS AND FACILITIES

Your are required to inform PMCare in writing one (1) month in advance of any intended change in the clinic operating hours or the facilities offered.

22.0 REGISTRATION OF PRACTICE

You shall provide PMCare your principal doctor’s valid Annual Practice Certificate (APC) every year. You shall also ensure that all medical practitioners engaged by you have valid APCs and are registered with Malaysian Medical Council (MMC).

23.0 REGULATIONS

You shall comply and abide to the rules and regulations set forth by the Ministry of Health and other governing regulatory bodies.




24.0 APPELLANT

If there is any grievance on matters related to the panelship arrangement by either party, the clinic or PMCare shall give written notice to the other party (addressed to either the Principal Doctor for the clinic or the Executive Director for PMCare) giving the respondent seven (7) days to respond. Whilst resolving the grievance, the complainant may opt to temporary suspend the panelship as provided under Clause 17.0.

25.0 TERMINATION

Either party, the clinic or TNB through PMCare can terminate the panelship appointment by giving thirty (30) days notice prior to the termination. At termination of panelship you are required to return to PMCare all properties, which belongs to PMCare such as panelship display sticker, and GP claims forms. PMCare also reserves the right to terminate your panelship when we deem it necessary without obligation to provide reason.

26.0 WORKING GUIDELINES You shall be subjected to the Working Guidelines for PMCare – TNB Panel of GP Clinics, attached herewith. The Working Guidelines describes in detail the working arrangement under the panelship appointment. Kindly be guided by it and make reference to it whenever required.

The Working Guidelines is subject to revision for which we shall keep you informed.

27.0 CONDITIONS PRECEDENT TO APPOINTMENT The following conditions should fulfilled when you are appointed as PMCare – TNB Closed Panel

of GP Clinics:

i. Acceptance of Letter of Offer for appointment; ii. Display PMCare – TNB Closed Panel Logo (For TNB Panel, Letter of Offer for

Appointment); and iii. Connected to Mediline.

PMCARE SDN BHD

WORKING GUIDELINES

FOR PMCARE – TNB CLOSED PANEL OF

GENERAL PRACTITIONER CLINICS

APPENDIX II

TABLE OF CONTENT PAGE

Chapter 1 PMCARE WORKING ARRANGEMENT FOR GP CLINIC

1.1 INTRODUCTION 1.2 PANELSHIP 1.3 PRINCIPAL DOCTOR 1.4 CLINIC ADDRESS 1.5 CLINIC CODE 1.6 INSTALLATION OF PMCARE MEDILINE SYSTEM 1.7 CLINIC IDENTIFICATION 1.8 MODES OF IDENTIFICATION OF PMCARE MEMBER 1.9 MEDICAL RECORD 1.10 DIAGNOSTIC INVESTIGATION 1.11 MATERNITY COVERAGE 1.12 REFERRALS 1.13 EXCLUSIONS 1.14 CHARGES 1.15 GP CLAIM SUBMISSION 1.16 SUBMISSION DEADLINE 1.17 COMMUNICATION 1.18 SUSPENSION OF SERVICE

Chapter 2 2.0 PMCARE – TNB CLOSED PANEL OF GP CLINIC STICKER

2.1 PMCARE – TNB MEMBERSHIP CARDS 2.2 LIST OF EXCLUSIONS ITEMS

Chapter 3 RECOMMENDED FEE SCHEDULE Chapter 4 IMMUNISATION CHARGES Chapter 5 DIAGNOSTIC INVESTIGATION

5.1 THE NECESSITY OF A DIAGNOSTIC TEST 5.2 FILLING IN YOUR CLINICAL DIAGNOSTIC REQUEST FORM 5.3 COMMUNICATING WITH PANTAI PREMIER PATHOLOGY (PPP) 5.4 MAKING A LABORATORY INVESTIGATION CLAIM FOR MANUAL

SUBMISSION 5.5 MAKING A LABORATORY INVESTIGATION CLAIM FOR YOUR

SERVICES Chapter 6 CLAIM SUBMISSION

6.1 MEDILINE CLAIMS 6.2 RETURNED OR QUERIED CLAIMS

Chapter 7 GUIDELINES FOR MEDILINE SUBMISSION ATTACHMENT Chapter 8 PMCARE GUIDELINES: SUMMARY Chapter 9 DIRECTORY FOR PROVIDER NETWORK MANAGEMENT UNIT

1 1 1 1 1 2 2

2 – 3 3

3 – 4 4 4 4 4

5 – 6 6 6 6 7 7

8 – 9

10 - 11

12

13

13–14 14 14

15

16 16

17 – 25

26 – 28

29 – 30

31

PMCARE SDN BHD WORKING GUIDELINES FOR

PMCARE – TNB CLOSED PANEL OF GP CLINICS CHAPTER 1


1.1 INTRODUCTION

The Working Guidelines is issued with the intention to provide clear description of the Terms and Conditions and the working arrangement between panel clinic and PMCare. Both clinic and PMCare are required to observe and comply with the Working Guidelines. Kindly take time to familiarize yourself with the Working Guidelines, which should also be made as reference for your daily operation. While every effort has been made to ensure the Working Guidelines is complete, comprehensive and simple, it is still subject to further improvement and revision from time to time of which, you will be informed. Lastly, we will also appreciate any feedback on the Working Guidelines from you.

1.2 PANELSHIP

Your clinic must be appointed to PMCare – TNB Closed Panel of General Practitioner (GP) Clinics and the appointment status is valid.

1.3 PRINCIPAL DOCTOR

The principal doctor for your clinic’s appointment to PMCare – TNB Closed Panel of GP Clinic is specified in the appointment letter. When there is any change in the principal doctor and/or clinic’s ownership, or other items in clause 20.0 and 21.0 under the Terms & Conditions of Appointment, please notify us in writing one (1) month prior to the intended change. We reserve the right to terminate your clinic’s appointment on the panel if for any reason to us; we find that the intended change is unsuitable for our business arrangement.

1.4 CLINIC ADDRESS

The clinic appointed to our panel is as specified in the Terms and Conditions of Letter of Offer of Appointment. During the term of appointment you shall operate at the appointed address. If there is any change in the clinic address, you are required to notify us in writing one (1) month prior to the intended change. We reserve the right to terminate your clinic’s appointment on the panel if for any reason to us; we find that the intended new business location is unsuitable for our business arrangement.

1.5 CLINIC CODE

Your clinic shall be given a PMCare clinic code, which shall be specified in your appointment letter. Please note that the clinic code is exclusive to the appointed clinic and shall not be used to represent any other clinic, branch or affiliated clinic. The clinic code shall help to facilitate communication and administer the business arrangement between clinic and PMCare.




1.6 INSTALLATION OF PMCARE MEDILINE SYSTEM

1.6.1 First Time Log In

Please log on to our web site www.mediline.com.my or www.pmcare4u.com.my and proceed to Mediline icon button using the following user ID and Password.

User ID: Password:

For security reason, you are advised to change the assigned password. Please familiarize yourself with the system by reading the Guidelines For Mediline (Chapter 7). If you have further queries, please call us for assistance.

1.7 CLINIC IDENTIFICATION

1.7.1 PMCare – TNB Closed Panel of GP Clinic Sticker

To facilitate our Members identify and access our panel clinics, all appointed clinics shall be identified by PMCare – TNB Closed Panel of GP Clinics sticker. PMCare – TNB Closed Panel of GP Clinics sticker should be displayed at all time during the term of appointment. The PMCare – TNB Closed Panel of GP Clinics sticker shall remain the property of PMCare at all times and shall be returned to us if your panelship is terminated for any reason. Please refer to Chapter 2 (Item 2.0) for sample of our existing PMCare – TNB Closed Panel of GP Clinics sticker.

1.7.2 How to Display Sticker

Please display the PMCare – TNB Closed Panel of GP Clinic sticker at a prominent place and most visible to public at the front area of your clinic such as the glass door or window panel. If in doubt of the position of display, please clarify with us.

1.8 MODES OF IDENTIFICATION OF PMCARE MEMBER

1.8.1 Types Of Identification (ID)

Every PMCare – TNB Member is given a TNB Membership Identification “ID” and is required to produce the ID whenever requesting for medical attention or service at the panel clinics. Clinic must use TNB Employee number in verification of patient. (For example 10001234 or 10012345).

1.8.2 Verification of Member

When a Member seeks for medical services at your clinic, kindly request for the

PMCare – TNB membership card and you shall verify it against either the National Registration Identity Card (“NRIC”) or the Driver’s license.




In the case of a child without the abovementioned cards, please check the parent / guardian membership card against either his/her NRIC or the Driver’s license. Please check the expiry date and provide treatment only to active cardholder.

i) Verification of Members For PMCare Mediline System

To check whether the member is an active member, please log into Mediline for verification. Please key in either the membership number or identity card number (old / new). Note that the dependants (spouse and children, where applicable) eligible for coverage are listed under the Employee. For details, please refer to Guidelines for Mediline Claim Submission (Chapter 7).

ii) Verification of Members For PMCare Manual System

The member should present his membership card together with a proof of identity card (NRIC). Please check the panelship, expiry date and the plan coverage. When in doubt, please contact PMCare to validate.

1.9 MEDICAL RECORD

Your clinic shall maintain records of every PMCare – TNB Member seen and treated at your clinic and obtain consent for the release of medical information for each visit by requesting the Member or the guardian (for minor) to sign a note of consent. Your clinic’s record shall include the following:

i) Member / Patient name and details ii) PMCare membership number iii) Date and time for each visit iv) Consent for the release of medical information v) Medical condition vi) Treatment and service rendered vii) Results of diagnostic tests and procedures, if any viii) Note on referral, if applicable

We reserve the right to review the abovestated clinic records for verification of claims. Your clinic shall provide to us on site review and / or submit to us copy of the records for the purpose.

1.10 DIAGNOSTIC INVESTIGATION

In the course of treatment to our Member, it may be necessary for you to require the Member to undergo diagnostic investigation. The diagnostic investigation must not be general screening in nature and the results of the investigation must assist you in making diagnosis for the Member. Please take note that ultrasound, sonotron services and chelation are not included in the type of diagnostic investigation allowed under the panelship arrangement and if conducted the charges shall not be claimable from PMCare.




When there is a need to conduct the diagnostic investigation, kindly request for written approval from PMCare by faxing to us ‘Diagnostic Investigation Request Form’ (see Chapter 5). For Laboratory investigation: If Pantai Premier Pathology services you, you are required to refer the Member to it. After conducting the diagnostic investigation, you are required to follow the GP Claim Submission procedure contained herein when making your claims for reimbursement (please refer Chapter 5).

1.11 MATERNITY COVERAGE

Please note that maternity benefits are only covered for TNB female employees and spouse of male employees. TNB retirees are not eligible for Maternity benefits.

Please contact PMCare to check whether Member prenatal and / or post -natal visits are

covered at GP panel clinic to avoid non-reimbursement from PMCare. Please take note that treatment can only be done at GP clinic and referral to specialist maternity care is only permitted in cases of complications. Should the member want to see an obstetrician for prenatal review even though there is no complication, it shall be done under ‘pay and claim’ basis, in which TNB shall reimburse 50 percent of the amount incurred.

1.12 REFERRALS

In the course of Member medical management, you may require to refer Member to other medical practitioners or facilities. Member referral should be done strictly based on your professional judgment and in the interest of best practice of medical management. Referral should not be made based on pressure from Member. All members are allowed to go to private facilities except for parents of TNB employees and husbands of female employees. To refer a Member, you shall fill up the Borang Pengesahan Rujukan ke Klinik/Hospital Pakar (BPR Form) to validate the referral. You may assist the Member by faxing the duly filled up form to our fax number 03-8023 9999. For maternity cases, referral to specialist care can only be done for patient in cases of complications.

1.13 EXCLUSIONS

Member healthcare benefit under PMCare – TNB program is subjected to exclusions (refer to List of Exclusion Items - Chapter 2). Please familiarize yourself with the exclusions and refrain from providing them.

1.14 CHARGES

You should be guided by the agreed schedule of charges under the appointment to PMCare – TNB Closed Panel of GP Clinic and MMA schedule of fees, whichever is lower when invoicing for services provided to our members. You are also required to provide details of services provided together with their respective charges.




1.15 GP CLAIM SUBMISSION

1.15.1 Mediline Claim Submission

Please follow on-line instruction and refer to Guidelines for Mediline Submission (Chapter 7) or our Provider Network Management Executive for further assistance. Your clinic is also required to submit to us copy of the authorization letter for medical examination, lab test result and / or X-ray report whenever applicable. Kindly refer Chapter 7 (Clause 7.1.1 to 7.1.2).

1.15.2 Manual Claim Submission

Your clinic is required to use Borang Rawatan Perubatan TNB and Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB when making claim for treatment and / or services provided to our member.

Your claim should include the following details:

1.15.2.1 Details of member’s visit;

i. Name of Employee ii. Employee number iii. Name of Employer iv. New NRIC No. or Old NRIC No. (where applicable) v. Name of Patient vi. Patient’s Membership No. vii. Relationship to Employee viii. Date and time of Visit ix. Signature of Patient/Guardian (if patient is a child)

1.15.2.2 Medical condition and/or diagnosis and treatment given; 1.15.2.3 Medication – describe prescription(s), drug name, dosage, amount

dispensed and itemized cost. 1.15.2.4 Injection – give drug name, dosage and route of delivery; 1.15.2.5 Nebuliser – give the drug (nebuliser fluid) name(s), number of time

of nebulizer given. 1.15.2.6 Toilet and suturing – indicate the number of sutures used; 1.15.2.7 Dressing – indicate the type of dressing done. e.g. Eusol dressing. 1.15.2.8 Minor surgery – indicate the nature of surgery. e.g. excision of

ganglion. 1.15.2.9 Other treatment procedures such as removal of foreign body, ear

syringing, suction. Indicate the type of procedure done with brief description;

1.15.2.10 X-Ray – indicate site and view(s) and attach a copy of the report with the Borang Rawatan Perubatan TNB.

1.15.2.11 Laboratory diagnostic test that is necessary for the medical condition and not general screening in nature. Indicate type of lab test and attach a copy of the lab result;

1.15.2.12 Medical (sick) leave certificate – please provide MC to deserving case and indicate number of days clearly;




1.15.2.13 Medical Examination – indicate the type of examination and attach copy of the employer’s or PMCare authorization letter with the Borang Rawatan Perubatan TNB and a copy of the lab result.

1.15.2.14 Please indicate your clinic code at the Borang Rawatan Perubatan

TNB and Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB as a reference.

1.15.2.15 Kindly ensure that every Borang Rawatan Perubatan TNB and

Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB is signed by your authorized personnel and affixed with your clinic’s stamp. Please be reminded that incomplete and / or illegible Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB may result in delay in payment or non-payment of your claims.

1.16 SUBMISSION DEADLINE

1.16.1 Via Mediline System

Kindly ensure accuracy and submit claims within 14 days of obtaining Authorization Code (AC). PMCare shall not be obliged to accept and pay claims that are submitted late i.e. beyond 14 days deadline for submission. Note: Please also see:

- Chapter 7 – Guidelines For Mediline Submission (Page 17 – 25).

1.17 COMMUNICATION

Please direct any enquiries, complaints or any form of feedback directly to PMCare and not to our clients, be it its employees and/or dependents. Kindly communicate with our Provider Network Executive or Medical Director for any inquiry (refer to Chapter 9 – Directory for Provider Network Management Unit). Your email address would be greatly facilitating communication between both parties. Remember to quote your clinic code each time communicating with us.

1.18 SUSPENSION OF SERVICE

Both the clinic and PMCare may suspend the panelship appointment for a temporary period of time by giving either party thirty (30) days written notice before the suspension.




2.0 PMCARE – TNB CLOSED PANEL OF GP CLINIC STICKER

2.1 SAMPLE OF PMCARE – TNB MEMBERSHIP CARD




2.2 LIST OF EXCLUSIONS ITEMS

The following is the list of conditions NOT COVERED by TNB:

2.2.1 Non-medical services provided by a hospital such as radio, television, telephone, fax, additional bed(s) or similar facilities.

2.2.2 Cosmetic surgery, cosmetic treatment, eye refraction, eximer laser for refractive

errors and hearing aids except as necessitated by injuries occurring wholly during the period of coverage.

2.2.3 Birth control, sexual dysfunction (e.g. Viagra), infertility investigation and

treatment, hormone replacement therapy. 2.2.4 Induced abortion with no medico. Legal indication. 2.2.5 Third party requested Medical Examinations including pre-employment, insurance

and routine physical examinations, blood-screening test not incidental to treatment or diagnosis of a covered disability, or any treatment which is not medically necessary or that not recognized to be medically acceptable.

2.2.6 Sickness or injury arising from racing of any kind, sky diving, scuba diving and

illegal activities. 2.2.7 Immunisation not officially recommended (on KKM Schedule of Immunisation) by

KKM e.g. Hepatitis A, Chicken pox, influenza. 2.2.8 Injuries sustained while committing a crime or felony. 2.2.9 Treatment for any form of disability, injury or sickness sustained or contracted due

to war or any act of war, terrorist activities, active duty in any armed forces, direct participation in strikes, riot and civil commotion.

2.2.10 Durable and disposable medical supplies (e.g. crutches, syringes contact lenses). 2.2.11 Non-therapeutic dietary supplements (including vitamins, soap, shampoo, vitamin

creams, evening primrose oil, omega 3 etc), appetite suppressants or anti obesity drugs, traditional or herbal products, anabolic steroids and pharmaceutical products not registered with the Ministry of Health. Alternative therapies such as acupuncture, reflexology, ozone therapy, chiropractic, etc.

2.2.12 Indemnity covered by other medical insurance (Ratable Proportion Contribution will

be applicable) as well as Worker’s Compensation Plan and SOCSO. 2.2.13 Circumcision




Note: Services are to be provided at service provider’s premise. Procedure for Ultrasound is

only valid for prenatal visits. Kindly refer the patient to a specialist clinic for ultrasound or for other diagnostic purpose. For any medical services that are not covered, PMCare or TNB shall not reimburse and the charges shall be borne by the patient.

(There may be some slight variation in the listed “Exclusions” for some selected healthcare program depending on our corporate clients’ employee medical benefits. Please refer to individual listing appended with your appointment letter for each type of panelship).




3.0 RECOMMENDED FEE SCHEDULE

Item Recommended charges Remarks

MEDICATION All medication must be itemized individually and will be reimbursed accordingly. Supply of medication for chronic cases should be on a monthly basis.

Antenatal - consultation RM 20

Antenatal - scanning RM 20

Antenatal – urine RM 15

Only members with maternity coverage. Look for “M” at the plan limit description on the membership card.

Blood withdrawal for 1x RM 10

Chest X-ray RM 30

Circumcision RM 80 Ritual circumcision for members with coverage.

Consultation RM 10 – RM 15 Including referral letter

Ear – syringing/toilet RM 10 - RM 15

ECG RM 30

FB removal RM50-RM80

Injection RM10-35 Refer to details on injection charges

Laboratory test Refer to Pantai Premier Lab charges as a guideline. For those subscribing to Pantai Premier Direct billing system, a blood-taking fee of RM10 is permissible for applicable tests

Med Exam – GDL and PSV New license RM 50

Renew license RM30 Requires letter of authorization from HR

Med Exam – Pre employment RM 30 Requires letter of authorization from HR

Nail Avulsion RM 60 – RM 80

Nebulizer RM 10 - RM15 See details below.

- Bricanyl / Ventolin RM10

- Combivent / Pulmicort RM15

- Duovent / Atrovent / Berotec RM15

Pap smear RM 25

Paraphymosis release RM 30

RBS (Random Blood Sugar) RM 10

STO RM 5

Urine dipstick RM 10




Item Recommended charges

Remarks

I & D Abscess RM 30 – RM50

Excision of cyst/ganglion RM 50 – RM 100

Toilet & Suturing RM 5 per stitch

Removal of foreign body (Ear/nose/ others)

RM 50 – RM 80

Dressing RM 15 – RM 25

These procedures need a brief description of treatment done. E.g. size and location of abscess, number of sutures and details of dressing.

Infra red Not covered

Aerochamber Not covered

Sonotron Not covered

Scan (ultrasound) Not covered Cover only for antenatal scan.

Referral letter Not covered

Registration Not covered

Disposable Not covered




4.0 IMMUNISATION CHARGES

Age Immunization Recommended charges

At birth BCG -

At birth Hepatitis B (1st dose) RM30

2 months Hepatitis B (2nd dose) RM30

2 months Diphtheria, Pertusis, Tetanus (DPT) and Polio with HiB (1st dose)

RM90

3 months Hepatitis B (3rd dose) RM30

3 months Diphtheria, Pertusis, Tetanus (DPT) and Polio with HiB (2nd dose)

RM90

5 months Hepatitis B (Booster dose) RM30

5 months Diphtheria, Pertusis, Tetanus (DPT) and Polio with HiB (3rd dose)

RM90

1 year MMR 1st dose RM45

1 ½ years 1st Booster - Diphtheria, Tetanus (DT), Polio RM55

5 – 7 years 2nd Booster - Diphtheria, Tetanus (DT) RM45

5 – 7 years MMR (Booster dose) RM45

15 years Tetanus Toxoid Booster RM20 Source – Kementerian Kesihatan Malaysia (KKM) – as at 1st January, 2006

Overseas Immunization requires letter of authorization from HR

Vaccination Product name Charges

Typhoid Typhim vi RM 75

Vivotif berna (oral) RM 60

Cholera RM 100

Meningococcal A&C YW RM 97

Oral polio RM 30

Malaria prophylaxis As per MIMS

Yellow fever RM 235

Injection charges Recommended charges

Ampicilline RM12

Bricanyl SQ RM12

Buscopan IM RM10

Chlorpheniramine / Piriton RM10

Dexamethazone RM10

Dimenhydrinate / Stemetil / Maxolon RM10

Gentamicin RM10

Lignocain 1cc RM3

Lincomycin 1cc RM15

Neurobion RM10

Prednisolone / Hydrocortisone RM10

Rocephine 250mg RM35

Triamcinolone / Diprospan RM20

Voltaren IM RM15




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5.0 DIAGNOSTIC INVESTIGATION

5.1 The Necessity Of A Diagnostic Test

5.1.1 Kindly be reminded that a diagnostic test should not be done at the

patient’s request or as a screening exercise.

5.1.2 Providers should choose tests that are directly relevant to the medical condition and understand the limitations in term of application of each test.

5.1.3 Providers must take full responsibility in interpreting the results and conveying them to respective patients, including the limitations of the tests conducted (5.1.2).

5.1.4 Depending on your requirement, obtain a specimen accordingly, and submit using appropriate specimen container(s) supplied by Pantai Premier Pathology Sdn Bhd.

5.2 Filling In Your Clinical Diagnostic Request Form

5.2.1 Please ensure that the patient is indeed a PMCare member eligible for the required test in accordance with your practice panel ship.

5.2.2 Fill in the NAME in CAPITAL LETTER followed by the MEMBERSHIP NUMBER as printed on the card.

Example: MOHD MARZUQ BIN IMRAN M-M-10012345-I

5.2.3 Write in your CLINIC NAME and CLINIC CODE preferably as:

KLINIK ABCDEFG PMCare X12345 (clinic stamp) 5.2.4 Tick at the “EMPLOYER” box.

(Please refer to sample for Pantai Premier Diagnostic Form)




-

Sample for Pantai Premier Pathology (PPP) Diagnostic Request Form 5.3 Communicating With Pantai Premier Pathology (PPP)

5.3.1 Inform the nearest PPP’s service office for the specimen collection. 5.3.2 Your specimen will be collected and within 1 to 5 days the lab report will be

delivered to you at your clinic.

5.3.3 On receiving the result/report, please take note of the Lab Number. You can appropriately advise your patient of the results.

5.4 Making A Laboratory Investigation Claim For Manual Submission

5.4.1 Pantai Premier Pathology will bill PMCare directly for the diagnostic tests. Therefore, please do not bill PMCare.

5.4.2 You are allowed to charge PMCare for blood taking procedure/specimen-

handling as follows: � Blood specimens – a flat fee of RM10.00 � Urine – nil � Swabs from sites (abscess; HVS) - a flat fee of RM10.00 � PAP smears - nil (to be charged as a procedure, at RM20.00) � HPE specimen - nil (to be charged as a procedure, e.g. excision of

lump).

Write your CLINIC NAME and CLINIC CODE as: Clinic Name, (Clinic Code) PMCare X12345 (clinic stamp)

Patient name, e.g.: MOHD MARZUQ BIN IMRAN (M-M-601325-03-1231-I)

Tick the “employer” box

Lab number


5.4.3 This charge should be written in the column provided for lab test charges in Borang Rawatan Perubatan TNB.

5.4.4 Please write in the Lab Number provided on the Lab Report by Pantai

Premier Pathology (PPP) on to the Borang Rawatan Perubatan TNB in the Lab (test) Column (manual or the Internet equivalent) as shown on below.

Sample on how to write your Lab number into the Manual GP Claim form

dhi2002

5.5 Making A Laboratory Investigation Claim For Your Services

Submission of a laboratory investigation claim is either through a Borang Rawatan Perubatan TNB or through Mediline. Please ensure that the column for Diagnostic procedures is filled up for Lab charges. Please attach the copy of the lab report together with Borang Rawatan Perubatan TNB. If you are using Pantai Premier laboratory services, please note the Lab No. If we did not receive the procedure and investigation items done, we may have to contact you and request the details. Indirectly, this shall delay the claim processing.

Note: Please also see

- Chapter 1 – Diagnostic Investigation Clause 10 (Page 3). - Chapter 7 – Making A Laboratory Investigation Claim For Mediline Submission Clause

7.1 (Page 25).




6.0 CLAIM SUBMISSION

6.1 Mediline Claims

Please ensure that the Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB is correctly filled up. All sections of the form must be completed accurately for prompt reimbursement. Failure to do so may result in delay in payment or even non-payment. If someone else is filling up this form for you, please ensure completeness before you place your signature and clinic stamp. Please refer Page 27 for sample of the form.

For some services, you are required to fax the following document(s) to Claims Dept, PMCare Sdn Bhd immediately upon claim submission through Mediline (if applicable): i) Medical or Laboratory Report ii) HR approval letter for Public Service Vehicle (PSV) License medical checkup iii) HR approval letter for Pre-employment medical checkup iv) HR approval letter for Good Driving License (GDL) medical checkup Kindly fax all the relevant documents to fax no.: 03 8026 6848 For easy reference and to expedite claim processing, you are advised to indicate the respective AC Code on the documents prior faxing to Claims Dept, PMCare Sdn Bhd. It is advisable that the Member verification, actual consultation and claim submission to be submitted immediately. However, it is permissible for the claims to be transmitted to PMCare by the 14th of the service date. PMCare will not be able to reimburse claims received after the deadline that is 14 days after the service date.

6.2 Returned or Queried Claims

Claims can be returned or queried to you with reasons stated on our letter (Ref: GP Claim Form(s) Returned). Your claims can also be queried for illegibility and inconsistencies in the information provided. You are advised to look seriously into these claims and return the claims to us. Please ensure that the rectification is done within seven days of receipt. This shall be considered as a ‘resubmission of claims’.

Note: Please also see

- Chapter 1 – GP Claims Submission Clause 1.15 (Page 5 – 6). - Chapter 1 – Submission Deadline Clause 1.16 (Page 6). - Chapter 7 – Guidelines For Mediline Submission (Page 17 – 25).




7.0 GUIDELINES FOR MEDILINE SUBMISSION

Step 1 - How To Access Our Portal

Use Internet Explorer version 5.0 and above or Netscape Navigator version 6.0 and above. Enter our portal at www.mediline.com.my or www.pmcare4U.com.my and subsequently proceed into the Mediline icon button.

Key in your User ID and Password. Click “Login” to go to Step 2.

If this is your first time login, please change your password for security purpose. The given User ID and Password is regarded as case sensitive. To train your staff, please use GUEST as User ID and guest2002 as password to avoid corrupting your claim record and is not meant for actual claim submission.




Step 2 – Patient Verification Screen

Verify your patients by the Member Type (select: Dependent or Member) or by ID Type, be it a Membership No., New I/C No. or Old I/C No. It is highly recommended to choose Employee Number. Click “Enter” to get the Authorization Code.

If the system states the patient to be an Invalid Member but the membership card is still valid, please contact PMCare to confirm on the validity.

Step 3 - Authorization Code (AC)

Click “Get Authorization Code” button to get the AC. The AC will automatically appear at the AC box. To start submitting your claims, click “Submit Claim”. Don’t forget! Your claim must be submitted within 14 days from the service date.




Step 4 – GP Claim Form Screen: How To Submit Your Claims

The verified / authorized member details will be automatically shown on the screen.

Step 4.1 Key in the visit date and visit time (based on Service Date and

Service Time).

Step 4.2 Key in the chosen Diagnosis from the 30 common diagnosis listing. If

diagnosis is not in the list, you may search from the Search Box.




Step 4.3 For Other Diagnosis, type in the diagnosis in the Diag Desc box and

click “Search”.

A Pop-up Window will come out with the result.

Step 4.4 Choose the desired diagnosis and click “Select”. The chosen

diagnosis will appear in the Selected area.




Step 4.5 Tick in the treatment information on the medication, itemizing the drugs

names, dosages and duration, which are COMPULSORY. Absence of these details shall result in delay in your claim processing.




Step 4.6 MC Days. Please enter 0 if no MC is issued. Step 4.7 To submit this claim straight away, click “Submit To PMCare”. The

claim will be transmitted into PMCare server. Step 4.8 To save, click “Save” button to continue with the next submission. To

check this claim again, go to “Pending Claim Listing” and click at the claim’s row. The GP Claim Form screen will appear again. Later you need to click ‘Submit to PMCare’ for claims under ‘Pending Claim Listing’ to submit these claims into PMCare server.




Step 5 – Report:

Step 5.1 To view your summary of claims by all clients or segregated into companies, click “Claims Summary” or “Summary by Company” under Report Menu. Key in the “start date”, the “end date” and click “View Summary”. To keep a copy of monthly report for your record, click “Print”.




Step 5.2 To generate your invoice, click at “GP Invoicing”. You need to key in

the “start date” and the “end date” to “view summary”. Please bill us using Mediline GP Invoicing Listing by courier or mail.




7.1 Making A Laboratory Investigation Claim For Mediline Submission

7.1.1 Check the “Others (Diagnostic procedures, lab tests)” in the Mediline GP claim form at the check box. Please refer to Mediline GP Claim Form below.

7.1.2 Write the Lab Number provided in the provided text box. Please refer to Mediline GP Claim Form below.

Sample on how to write your Lab number into the Mediline GP Claim Form

Note: Please also see - Chapter 1. Diagnostic Investigation Clause 1.10 (Page 3). - Chapter 5. Diagnostic Investigation (Page 13 – 15).

Key in the Lab

No. here

ATTACHMENT


ATTACHMENT 1

BORANG DAFTAR RAWATAN UNTUK KAKITANGAN DAN TANGGUNGAN TENAGA NASIONAL BERHAD

(200866-W)

NAMA KLINIK: ………………………………………………………………… KOD KLINIK: ………………………………… BULAN:………………………………

Tandatangan Doktor: …………………………………………. Cop Klinik:

Tarikh: …………………………… MD/MM-10, Rev 0, Eff Date: 29/07/08 Borang Daftar Rawatan TNB_Rev 0

Saya membenarkan doktor yang merawat saya memberikan maklumat lawatan saya

kepada majikan / PMCare.

Bil.

Tarikh Rawatan

Nama Pekerja / Pesakit

No. Pekerja TNB

Tandatangan Pekerja / Pesakit


ATTACHMENT 2

BORANG PENGESAHAN RUJUKAN

KE KLINIK / HOSPITAL PAKAR (Borang BPR)

Kepada : PMCare Sdn Bhd

No. Fax : 03-8023 9999 (fax server) Nama Pekerja : .................................................................................... No. Pekerja : ........................................ Nama Pesakit : .......................................................................................... No. K/ P : .............................................. No. Tel. Pekerja / Pesakit : ................................................. No. Fax Balik : ....................................... No. Tel Bimbit pekerja / Pesakit:......................................... ____________________________________________________________________________________________________ Saya telah memeriksa pesakit di atas dan mengesahkan beliau memerlukan tindakan berikut:

Dirujuk untuk rawatan pakar sebagai pesakit luar

Dimasukan ke wad di hospital / rawatan kecemasan di hospital

Dirujuk untuk pemeriksaan X-ray / MRI / Ultrasound

Lain-lain (sila nyatakan)

Pesakit Dirujuk Kepada : .................................................................................................................................…………………………………………….. (Nama Doktor / Kepakaran) . ...............................................................................................................................…………………………………………….. (Nama Klinik / Hospital Pakar) No. Fax Klinik / Hospital : ............................................... Tarikh Temujanji : ...................................... Diagnosis : ..........................................................................................................................................……………………………………

...................................................... Tarikh : ................................ (Tandatangan Doktor / Cop Klinik)

Kebenaran daripada yang membuat tuntutan atau pesakit: Saya, seperti nama di atas, dan/atau wakil kepada tanggungan saya dengan ini membenarkan laporan perubatan dikeluarkan kepada PMCare Sdn Bhd dan Tenaga Nasional Berhad. ............................................................. Nama : No. K/P :

Catitan: Sila pastikan bahawa rujukan dibuat ke klinik / hospital yang terdekat dengan

stesen pekerja / pesakit

OPS/GL-DA-12, Rev 1, Eff Date: 29/07/08 TNB_Borang Pengesahan Rujukan _Rev 1




8.0 PMCARE GUIDELINES: SUMMARY

8.1 PMCare – TNB Closed Panel Sticker – Please display your sticker at a prominent place as to be seen clearly by the members.

8.2 Verify your Patient – Each Member may present with a valid TNB membership card,

be it the employee or their dependents. A valid proof of identity, such as identity card should be sought. We strongly suggest you to verify the Member through Internet (Mediline). The burden of proof to verify the validity and eligibility of the member lies on the clinic on providing the service. If you are still offline, kindly contact us for Mediline registration. Should you have doubt over the verification, please contact us through our 24 hours Careline at 1-300-88-6868.

8.3 Treatment and Charges – Kindly render your professional services as deemed

necessary. While there is no limit to the amount charged, you are expected to justify all items charges. Referral should not be made at a patient’s request but rather as an exercise of your professional judgment. Please be aware of your patient’s entitlement when you act on this. Kindly write the referral letter clearly and advise the specialist concerned to refer back the patient to you as soon as he / she is stable with appropriate advice.

8.4 Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB – This form

should be duly filled up by member at the point of registration and completed by the attending doctors. These should be submitted to PMCare before 7th of the month after the service month along with the Mediline GP Invoice Listing.

8.5 GP Claim Submission – Submission through Mediline should be done daily whenever

possible, and the latest submission is within 14 days from the service date. You can check whether the claims have been submitted by viewing “Claims Summary” (refer Chapter 7, step 5). Please be reminded that the submission is considered complete when all below are safely received by PMCare:

8.5.1 Claims via Mediline. 8.5.2 Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB 8.5.3 Mediline GP Invoice listing duly signed and stamped.

For TNB Dental clinic, kindly submit Borang Rawatan Perubatan TNB and Borang Daftar Rawatan Untuk Kakitangan dan Tanggungan TNB for the month of services to us before the 15th of the following month. Claims over 60 days from the date of service will be rejected. Claims on persons not eligible for medical services, incomplete information and wrong clinic code will be rejected.

8.6 Internet Connection – To register your connection with our Mediline, please contact

03 - 8026 6865 for creation of User ID and Password.




8.7 Claim Disputes – Your claims will be scrutinized for validity and appropriateness of

treatment and charges. Claims that are invalid, incomplete, inappropriate will be rejected and sent back to you with explanatory note of the reasons for rejection. If a remedy can be offered, we will accept it again for resubmission.

8.8 Claim Reimbursement – Your claims will be processed and payment shall be made to

you within 60 to 90 days after the date of receipt of your claims.

8.9 Uninterrupted Services – You are to provide services without interruption to our members unless you choose to terminate this services arrangement with us. Such intention for termination must be notified to us in writing and reach us at least 30 days from the date you plan to stop providing the services. Upon termination, you are required to remove our panel display sticker.

8.10 Communication – Please direct any enquires, complaints or any form of feedback

directly to PMCare and not to our clients, be it its employees and / or dependents. Your email address would be greatly facilitating communication between both parties.




9.0 DIRECTORY FOR PROVIDER NETWORK MANAGEMENT UNIT

No.

Medical Department

Telephone E-Mail

1. Dr. Mohd Helmi Ismail Director, Medical Management

03-8026 6861 [email protected]

2. Dr. Benjamin Sinappan

Director, Medical Services


PROVIDER NETWORK – HOSPITAL & SPECIALIST UNIT

3. Nurullydia Ahmad

Provider Network Executive


4.

Tengku Muhammad Sunaidi B. Tg Ismail Provider Network Executive

03-8026 6879

[email protected]

5. Syahrul Nizam Baharudin Provider Network Executive


6.

Noor Suhaida Shariff

Provider Network Sr. Clerk


7. Faezah Ibrahim Provider Network Sr. Clerk

03-8026 6875 NA

8. Masykurah Muhamad Abdullah Provider Network Clerk

03-8026 6873 NA

PROVIDER NETWORK – GP CLINIC UNIT

9. Siti Asmah Ahmad Hamdan Provider Network Executive


10. Nazrulsyah Firaz bin Fauzee Andylim

Provider Network Executive


11.

Wan Zaimah Wan Zahari Provider Network Executive


12. Sarenawaty Md Reduan Provider Network Sr. Clerk


13. Mazura Abdul Hamid

Provider Network Clerk

03-8026 6849 NA

14. Mohd Hafizee Ismail Provider Network Executive

NA NA

15. Norwatilah Shood Provider Network Clerk


MEDICAL MANAGEMENT UNIT

16. S. Mahandrran

Medical Management Sr. Executive


17. Zaini Che Ghani

Medical Management Sr. Executive


18. Azni Abu Bakar Medical Management Executive


19. Khairul Norziana Kamarudin

Medical Management Executive


20. Josniha Joehari

Medical Management Sr. Clerk


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