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PMCARE SDN BHD

TERMS AND CONDITIONS

FOR

PMCARE PANEL OF

GENERAL PRACTITIONER CLINICS

APPENDIX I

PMCARE SDN BHD

TERMS AND CONDITIONS OF

PMCARE PANEL OF GP CLINICS

Effective Date: 09/07/2012, Revision 7 1

1.0 PANELSHIP

Your clinic shall be appointed to our PMCare (type of panelship). 2.0 CLINIC NAME

The offer for the appointment is for (submitted name of Clinic), hereafter referred to as the clinic.

3.0 CLINIC ADDRESS

Your clinic business address is: Submitted address of Clinic line 1 Submitted address of Clinic line 2 Submitted address of Clinic line 3 Submitted address of Clinic line 4

Under the panelship, you are only authorized to conduct business at the above stated address. The address shall also be considered as your official correspondence address where all correspondences or notices shall be addressed. Should there be any changes, you are to advise us supported by appropriate documentations and approval from authorities. We reserve the right to reassign the panelship based on the documentations and location provided.

4.0 OWNERSHIP OF CLINIC The registered and legal owner of this clinic is (submitted Owner of Clinic). Under the Panelship, you are only authorized to conduct business based on the abovementioned ownership. Should there be any changes, you are to advise us supported by appropriate documentations. We reserve the right to re-assign the Panelship based on the documents provided.

5.0 CLINIC CODE

Your clinic code is (Clinic Code). 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 PRINCIPAL DOCTOR The Principal Doctor for this appointment is (Name of Principal Doctor).

Should there be any changes, you are to advise us supported by appropriate documentations.

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7.0 MODE OF OPERATIONS AND SUBMISSION You shall conduct business through the Internet based PMCare Mediline™ System supported by PMR Instant Verification System unless otherwise stated.

As a PMCare panel clinic, you are required to have Internet ready computer system to enable you to implement our Mediline system applications before commencement of the panelship. You are to also subscribe to the Instant Verification System (currently PMR) as and when approached. You shall submit all claims through Mediline system within the stipulated time limit, failing which you shall be barred from submission. All submissions via Mediline system shall be subjected to a nominal processing fee of RM0.20 for every successful transaction. Manual submission made within 30 days of the end of service month shall be considered when accompanied by an appropriate written explanation and subject to a further processing charge of RM2.00 per transaction. Late submission shall be subject to the rules imposed by individual payers.

8.0 CLINIC IDENTIFICATION

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

9.0 PROVISION OF SERVICES – MEDICAL ATTENTION, TREATMENT AND

ANCILLIARIES TO PMCARE MEMBERS

You shall provide services only to valid PMCare 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 program.

10.0 PROVIDER AUDIT

As a PMCare panel provider, you shall be subjected to the clinical audits and/or procedural audits, which shall be performed from time to time to ensure compliance to the Terms & Conditions and the Working Guidelines.

11.0 MAINTENANCE OF RECORDS AND CONSENT Your clinic shall maintain record of every PMCare 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 above stated clinic records for verification of claims. Your clinic shall provide to us on site review and/or submit to us copy of record for the purpose. We reserve similar right to request for adequate on-site visits, interviews with clinic personnel and inspection of documents to

PMCARE SDN BHD




substantiate these claims in a GP Service Provider Audit by giving you a notice of not less than 24 hours.

12.0 EXCLUSION

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

13.0 CHARGES

Your charges for the services provided to our Members shall be guided by the agreed schedule of fees under the panelship appointment and prevailing Schedule of Fees. We strongly advise that the charges be made known to your patients - preferably in print – at the end of the clinic visit.

14.0 MEDILINE™ CLAIMS SUBMISSION

14.1 Deadline for Claims Submission

Your clinic is required to submit to us your Mediline™ GP claims within three (3) days of date of service provided to our member. Claim that is submitted late shall not be accepted or payable.

14.2 Invoicing

All panel clinics are required to submit to us Mediline™ GP Invoicing Listing on a weekly, fortnightly or at least monthly basis. The listing must be duly signed by your clinic’s authorized signatory and stamped with your clinic’s stamp.

For some services, you are required to fax the following document(s) together with GP Visit and Consent Form to Claims Dept, PMCare immediately upon claim submission through Mediline™ (if applicable): i) Clinic Visitation (e.g. TNB, IWK) Form duly filled up ii) Medical or Laboratory Report iii) HR approval letter for Public Service Vehicle (PSV) License medical

checkup iv) HR approval letter for Pre-employment medical checkup v) HR approval letter for Good Driving License (GDL) medical

checkup

Failure to submit the above absolves PMCare the obligation to pay for the claim and be subjected to an appeal to the payor with the discretion to decide on payment. This decision shall be final. Forms or letters that are incomplete or incorrect or illegible will not be accepted or payable.

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15.0 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 seven (7) days from date of letter for written query. PMCare shall make adjustment on the submitted charges based on these responses. Failure to response absolves the right to object to these adjustments.

16.0 DEDUCTIONS FROM AMOUNT CLAIMED

Deductions might be made from: i. Exceptionally high charges as compared to industry benchmarks; ii. Adjustment to charges arising from each claim considered inappropriate

from Queried Claims; iii. Service charge for claims successfully received, processed and approved for

payment at prevailing rate per claim; iv. RM2.00 MEPS-IBG charge or RM5.00 Rentas charges by the bank for the

payment made by PMCare via MEPS-IBG or Rentas; v. RM240.00 Annual Maintenance fee for maintaining PMR Instant Verification

System; vi. RM2.00 per claim for late submission claim processing charges which shall

subject to the rules imposed by the individual payers; and vii. Agreed donation as consented to in any PMCare Charity Fund Raising

Exercise – RM10.00 from total amount claimed for the month. 17.0 GP CLAIMS SETTLEMENT

PMCare shall accept and process your claims for reimbursement that are complete and timely as per Clause 14.0. 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 iii. Medical examination conducted without proper authorization and

incomplete documents iv. Claims queried by PMCare (Clause 15.0)

The payment for queried claims shall be made within 60 days after the queries had been satisfactorily responded to and rectified by your clinic. Item (iii) and those awaiting documentations (Clause 14.0) shall be deemed payable 60 days on receipt of the complete documents. Items (i) to (ii) shall not be payable.

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18.0 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 that we may introduce from time to time.

19.0 UNINTERRUPTED SERVICE

You shall provide uninterrupted service to our Members except for period of temporary suspension of service (see Clause 20.0). 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.

20.0 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.

21.0 PROVISION OF SERVICES FOR UNCOVERED ITEMS

At your discretion, your clinic may provide services to our Members for items not covered under PMCare 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.

22.0 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 should have been earlier 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.

23.0 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 together with the relevant supporting documents. PMCare reserves the right to terminate the appointment if for any reason PMCare finds the intended change is unsuitable.

PMCARE SDN BHD




24.0 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.

25.0 REGISTRATION OF PRACTICE

You shall ensure that your clinic is duly licensed as required by the Private Healthcare Facilities and Services Act (1998) and Regulations (2006) and a copy of the license shall be submitted to PMCare.

You shall also provide PMCare a certified copy of your principal doctor’s valid Annual Practice Certificate (APC) every year not later than 31st of May. You shall also ensure that all medical practitioners engaged by you have valid APCs and are registered with Malaysian Medical Council (MMC). You shall provide a certified copy of the Full Registration Certificate of all above when requested for.

26.0 REGULATIONS

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

27.0 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 20.0.

28.0 TERMINATION

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

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

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

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30.0 CONDITIONS PRECEDENT TO APPOINTMENT The following conditions shall be satisfied prior to your appointment as PMCare

Panel of GP Clinics: i. Acceptance of Letter of Offer for appointment, ii. Attendance to a PMCare Panel Clinic Induction Program (unless

exempted), iii. Proven on-site connection to Mediline™; and iv. Willingness to use PMR Instant Verification System with computer onsite.

PMCARE SDN BHD

WORKING GUIDELINES

FOR


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 Access To 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

Chapter 2 - PMCARE PANEL OF GP CLINIC STICKER Chapter 3 - PMCARE MEMBERSHIP CARDS

3.1 Membership cards for Closed Panel Stickers - Smart Card 3.2 Membership cards for Closed Panel Stickers - PVC Card 3.3 Membership cards for PMCare Open Panel Sticker 3.4 Membership cards NOT APPLY for GP visit 3.5 Membership cards for Co-Payment Program

Chapter 4 - LIST OF EXCLUSIONS Chapter 5 - RECOMMENDED FEE SCHEDULE Chapter 6 - IMMUNISATION CHARGES Chapter 7 - DIAGNOSTIC INVESTIGATION

7.1 The Necessity of A Diagnostic Test 7.2 Filling in Your Clinical Diagnostic Request Form 7.3 Communicating With Pantai Premier Pathology (PPP) 7.4 Making A Laboratory Investigation Claim for Manual Submission 7.5 Making a Laboratory Investigation Claim for Your Services

Chapter 8 - CLAIMS SUBMISSION

8.1 Mediline™ Claims 8.2 Submission of Mediline™ GP Invoicing Listing

Chapter 9 - GUIDELINES FOR MEDILINE™ CLAIM SUBMISSION Chapter 10 - PMCARE WORKING GUIDELINES: SUMMARY APPENDIXES: APPENDIX 1 - DIRECTORY FOR MEDICAL DEPARTMENT STAFF APPENDIX 2 - REFERRAL LETTER FORM TO SPECIALIST

1 1 1 1 2 2

2 - 3 3 - 4 4 5 5 5 6 6 6 7 7 8 9 9

10 - 11 11 11

12 - 15

16- 17

18

19 19 20 20 21

22 22

23 - 31

32

33 & 34 35 & 36

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WORKING GUIDELINES FOR PMCARE PANEL OF GP CLINICS

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1.0 PMCARE WORKING ARRANGEMENT FOR GP CLINIC 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. Whilst 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 for 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 Sdn. Bhd. (“PMCare”) Panel of General Practitioner (GP) Clinics and the appointment status is valid.

There are 2 types of PMCare panel of GP clinics, namely: i) PMCare Open Panel; and ii) PMCare Closed Panel such as PMCare-Telekom Panel of GP Clinics and

PMCare-BSN Panel of GP Clinics. A clinic can either be appointed to only PMCare Open Panel or to a combination

of PMCare Open and Closed Panel. Our appointment letter will indicate the type of panelship your clinic is appointed to.

1.3 PRINCIPAL DOCTOR

The principal doctor for your clinic’s appointment to PMCare 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 23.0 and 24.0 under the Terms & Conditions of Appointment, please notify us in writing 1 month prior to the intended change together with the relevant supporting documents. 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 together with the relevant supporting documents. 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.

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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 facilitate communication and help administer the business arrangement between clinic and PMCare.

1.6 ACCESS TO PMCARE MEDILINE™ SYSTEM 1.6.1 Mode of Operation

You shall conduct business through PMCare Mediline™ system.

As a PMCare Mediline™ clinic, you are required to have Internet ready computer system to enable you to implement our Mediline™ system applications. Our application is best viewed in Internet Explorer version 5.0 and above and can be accessed through our portal www.pmcare4u.com.my and proceed to Mediline™

icon button.

1.6.2 First Time Log In

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

User ID: 101399 Password: PSWD101399

For security reason, you are advised to change the assigned password. Please familiarize yourself with the system by reading the Guidelines For Mediline™ Claim Submission (Chapter 9). If you have further queries, please call us for assistance.

1.7 CLINIC IDENTIFICATION

1.7.1 PMCare Panel of GP Clinic Sticker

To facilitate our Members identify and access our panel clinics, all appointed clinics shall be identified by PMCare Panel of GP Clinics sticker. PMCare Panel of GP Clinics sticker should be displayed at all time during the term of appointment. The PMCare 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 for samples of our existing PMCare Panel of GP Clinics sticker.

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1.7.2 How to Display Sticker

Please display the PMCare 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)

PMCare Member may be given a PMCare Membership Identification “ID” and he/she is required to produced the ID whenever requesting for medical attention or service at the panel clinics. There are 2 types of PMCare Member ID; namely membership card and medical log book.

The following are examples of existing PMCare Member ID:

i) Membership Card

a) PMCare Closed Panel Program b) PMCare Open Panel Program c) PMCare Select Access Program d) PMCare Co-Payment Program e) PMCare Smart Card f) PMCare ‘Kad Hospital’

ii) Medical Logbook

a) Limited Panel of GP Clinics Medical Logbook

The medical logbook will specify the name of clinics, which allow the Member to visit. Only GP clinic(s) specified in the logbook is (are) allowed to provide services to the Member under the program.

b) Limited Number of Visits Medical Logbook

The medical logbook will specify the type of panel and the maximum number of visits per annum the Member is allowed to visit under the program. GP clinics are required to verify that the Member has not utilized the maximum number of visits before providing service to the member (patient) under the program and record in the medical logbook each time service is provided to the member.

Please note that from time to time, PMCare may introduce new modes of identification of PMCare members. Your clinic shall be duly informed. We have already embarked on the use of MyKad or/and MyKid for member identification along with PMCare MyKad Reader (PMR) as a device connecting to Internet for easy and safer member verification.

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For samples of existing modes of identification of PMCare members, please refer to Chapter 3 - PMCare Membership Cards.

1.8.2 Verification of Member

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

the PMCare 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 using PMCare MyKad Reader (PMR)

MyKad or MyKid, presumably not defective, can be used with a device connected to a personal computer that is again connected to Internet. When appropriate, a PMCare smartcard is issued and this can be used in place of MyKad/MyKid.

ii) 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 9).

iii) 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.

1.8.3 When in doubt as to the eligibility of the individual as our member, please call our Careline to avoid unnecessary denial of service.

1.9 MEDICAL RECORD

Your clinic shall maintain record of every PMCare 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

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vii) Results of diagnostic tests and procedures, if any viii) Note on referral, if applicable.

We reserve the right to review the above stated clinic records for verification of claims. Your clinic shall provide to us on site review and / or submit to us copy of record 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 the nature and the results of the investigation must assist you in making diagnosis for the Member.

Imaging techniques are confined to plain X-rays. Ultrasound scans are allowable only in antenatal follow-ups in a valid Maternity Program.

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 7). 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.

1.11 MATERNITY COVERAGE

Limited Members enjoy maternity healthcare benefit. The following plan details in the Members card will help to identify this benefit.

GP – M (prenatal is covered at GP panel clinics)

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 in most cases for the first seven (7) months of pregnancy, treatment can only be done at GP clinic and referral to specialist maternity care is only permitted in the third trimester, unless in cases of complications.

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. Please familiarize yourself with Member’s eligibility for referral either to government or private facilities. Referral Letter To Specialist Form can be found and downloadable through our Mediline. (Refer Appendix 2 for sample)

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For maternity cases, referral to specialist care can only be done for patient in the third trimester unless in case of complications.

1.13 EXCLUSIONS

Member healthcare benefit under PMCare program is subjected to exclusions (refer to List of Exclusion - Chapter 4). Please familiarize yourself with the exclusions and refrain from providing them. Please take note that ultrasound, sonotron, ozone and chelation therapy; and any other mode considered NOT evidence-based are not included in the type of treatment allowed under the panelship arrangement and if conducted the charges shall not be claimable from PMCare.

1.14 CHARGES

You should be guided by the agreed schedule of charges under the appointment to PMCare Panel of GP Clinic and prevailing 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

Claims submission shall be done through PMCare Mediline™ Internet application module. Please ensure that the Mediline™ module is in order. Please follow on-line instruction and refer to Guidelines for Mediline™ Claim Submission (Chapter 9) 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 to 7.5). Please provide the following details: 1) Medical condition and/or diagnosis and treatment given. 2) Medication – describe prescription(s), drug name, dosage, amount

dispensed and itemized cost. 3) Injection – give drug name, dosage and route of delivery. 4) Nebulizer – give the drug (nebulizer fluid) name(s), time of nebulizer given. 5) Toilet and suturing – indicate the number of sutures used. 6) Dressing – indicate the type of dressing done. E.g. Eusol dressing. 7) Minor surgery – indicate the nature of surgery. E.g. excision of ganglion. 8) Other treatment procedures such as removal of foreign body, ear syringing,

suction. Indicate the type of procedure done with brief description. 9) X-Ray – indicate site and view(s) and attach a copy of the report. 10) Laboratory diagnostic 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.

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

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12) Medical examination – indicates the type of examination and attaches copy of the employer’s or PMCare authorization letter with the copy of the lab result.

13) Please indicate your clinic code as a reference. 1.16 SUBMISSION DEADLINE

Mediline™ System

Kindly ensure accuracy and submit claims within 3 days of obtaining Authorization Code (AC). Manual submission made within 30 days of the end of service month shall be considered when accompanied by appropriate written explanation and subject to a processing charge of RM2.00 per transaction. PMCare shall not be obliged to accept and pay claims that are submitted late i.e. beyond deadline for submission. Note: Please also see: - Chapter 8 – Claims Submission - Chapter 9 – Guidelines for Mediline™ Claim Submission

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 11 – Directory for Medical Department Staff). Your email address would be greatly facilitating communication between both parties. Remember to quote your clinic code each time communicating with us

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CHAPTER 2

Effective Date: 09/07/2012, Revision 7 8 8

2.0 PMCARE PANEL OF GP CLINIC STICKER

The following are samples of our existing logos:

2.1 PMCare Open Panel Sticker

2.2 PMCare Closed Panel Stickers

2.2.2 PMCare – TM GP Closed Panel Clinic Sticker

2.2.4 PMCare – IWK GP Closed Panel Clinic Sticker

2.2.3 PMCare – BSN GP Closed Panel Clinic Sticker

2.2.5 PMCare – CIMB Closed Panel GP Clinic Sticker

2.2.1 PMCare – TNB GP Closed Panel Clinic Sticker

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3.0 PMCARE MEMBERSHIP CARDS

3.1 Membership cards for PMCare Closed Panel Stickers – Smart Card A. PMCare Smart Card – TNB Medical Card B. PMCare Smart Card – TM Medical Card

3.2 Membership cards for PMCare Closed Panel Stickers – PVC Card C. PMCare – CIMB Bank Medical Card D. PMCare – BSN Medical Card

1. PMCare – BSN membership card. 2. Valid at BSN closed panel clinic only. If you

are NOT APPOINTED as BSN closed panel clinic, please COLLECT CASH from member for GP treatment.

1. PMCare – TM membership card. 2. Valid at TM closed panel clinic only. If you are

NOT APPOINTED as TM closed panel clinic, please COLLECT CASH from member for GP treatment.

1. PMCare – CIMB Bank membership card. 2. Valid at CIMB Bank closed panel clinic only. If

you are NOT APPOINTED as CIMB Bank closed panel clinic, please COLLECT CASH from member for GP treatment.

1. PMCare – TNB membership card. 2. Valid at TNB closed panel clinic only. If you

are NOT APPOINTED as TNB closed panel clinic, please COLLECT CASH from member for GP treatment.

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3.2 Membership cards for PMCare Open Panel Sticker

3.2.1 PMCare Open Panel Program

E. PMCare Medical Card F. PMCare Medical Log Book

1. PMCare – Open panel membership card. 2. Valid in all PMCare – Open panel clinics 3. If you are NOT APPOINTED as PMCare Open

panel clinic, please COLLECT CASH from member for GP treatment.

1. PMCare Medical Log Book. 2. Valid in all PMCare – Open panel clinics 3. Limits for benefit shall be specified under

column Coverage Plan Limits (if applicable) 4. Please stamp and sign for every visit. 5. Please indicate amount incurred for

each visit at the column provided. 6. If you are NOT APPOINTED as PMCare Open

panel clinic, please COLLECT CASH from member for GP treatment.

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Effective Date: 09/07/2012, Revision 7

11

3.2.2 PMCare Select Access Program G. PMCare - UMW Medical Card

3.3 PMCare Membership Cards NOT APPLY for GP visit

H. PMCare Hospital Card

3.4 PMCare Membership cards for Co-Payment Program

I. PMCare – Symphony BPO Solutions Card

1. PMCare – UMW membership card. 2. The UMW member selected 2 clinics as their panel

that appears on the membership card. 3. Valid only in SELECTED PMCare Open panel clinics. 4. If you are NOT SELECTED as PMCare-UMW select

access program, please COLLECT CASH from member for GP treatment.

1. This card is ONLY for admission at hospitals. 2. Please collect cash from member for GP

treatment.

1. Please collect RM5 direct from the member by reminding him/her of the wording “Co-Payment RM5” on the card.

2. Provide treatment as required subject to Working Guideline.

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WORKING GUIDELINES FOR


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12

4.0 LIST OF EXCLUSIONS

4.1 List of Standard Exclusions Following is the list of conditions and situations not covered by PMCare:

4.1.1 Pre-existing Conditions or hospital confinement occurring within the first thirty (30) days from the commencement of this Certificate due to illnesses unless the Person Covered affected by these conditions has been covered under this Certificate for twelve (12) months or has been continuously covered under a group hospital and surgical takaful or insurance immediately prior to the commencement of this Certificate.

4.1.2 Congenital abnormalities or physical defects present at birth.

4.1.3 Treatment arising from pregnancy which shall include childbirth and any complication

resulting from pregnancy, miscarriage except as a result of an accident, diagnostic test for pregnancy, test to do with and treatment for subfertility or infertility, abortion or sterilisation and contraception including any complications relating thereto.

4.1.4 Outpatient treatment including outpatient physiotherapy treatment except as a result

of an accident ,preventive care including routine health checks, charges for private nursing, precautionary services, acupuncture, chiropractic, homeopathy treatment, services received in convalescent and nursing home, nature cure clinics, isolation or quarantine by law from any communicable diseases.

4.1.5 Charges which are not for actual necessary and reasonable expenses incurred in the

treatment of the illness or injury, charges for telephone ,television, news papers and other non medical items.

4.1.6 Eye tests, refractive errors for eyes, expenses for procurement or use of special

braces or prosthesis including spectacles, hearing aids, wheel chairs and lenses. 4.1.7 Dental care, treatment or surgery unless necessitated by injury caused by accident. 4.1.8 Treatment or surgery for tonsils, adenoids, hernia or a disease peculiar to the female

generative organs unless the Participant has been continuously covered under this Certificate for a period of more than one hundred and twenty (120) days.

4.1.9 Treatment for obesity ,weight reduction or weight improvement ,circumcision, any

elective surgery or treatment which is not medically necessary ,cosmetic or plastic surgery for the purpose of beautification.

4.1.10 Treatment arising from any geriatric, psychogeriatric conditions, or treatment to

improve the psychological, mental or emotional well-being, abuse of drugs or alcohol.

4.1.11 Expenses incurred for donation of any body organ by the Person Covered and costs

of acquisition of the organ including all costs incurred by the donor during organ transplant.

PMCARE SDN BHD



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13

4.1.12 Expenses which are payable under the Workmen’s Compensation or other insurance

or takaful.

4.1.13 Injury or illness occurring directly or indirectly from war (whether war be declared or not) or warlike operations, invasion, act of foreign enemies, hostilities, civil war, mutiny, civil commotion assuming the military uprising, insurrection, rebellion, military or usurped power or any act of the Person Covered acting on behalf of or in connection with any organization actively directed towards the overthrow by force of any government or to the influencing of it by terrorism or violence.

4.1.14 Injury or illness due to directly or indirectly from nuclear weapons material, ionising,

radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel. Solely for the purpose of this exclusion, combustion shall include any self-sustaining process of nuclear fission.

4.1.15 Any breach of law by the Participant of any assault provoked by him. 4.1.16 Attempted suicide or self-inflicted injury whilst sane or insane. 4.1.17 Aviation, gliding or any other form of aerial flight other than as a pilot, cabin crew

or fare paying passenger of a recognised airline or charter service. 4.1.18 Participation in or training for any dangerous or hazardous sport or competition or

riding or driving in any form of race or competition. 4.1.19 Acquired Immunodeficiency Syndrome (AIDS), infection by Human

Immunodeficiency Virus (HIV) or related conditions. Note: Services are to be provided at service providers’ premise. Procedure for Ultrasound is

not payable under GP treatment. Kindly refer the patient to a specialist clinic for ultrasound. For any medical services that are not covered, PMCare 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).

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14

4.2 List of Exclusions for TNB

The following is the list of conditions not covered by TNB:

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

4.2.2 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.

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

hormone replacement therapy. 4.2.4 Induced abortion with no medico. Legal indication. 4.2.5 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.

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

activities. 4.2.7 Immunisation not officially recommended (on KKM Schedule of Immunisation) by

KKM e.g. Hepatitis A, Chicken pox, influenza. 4.2.8 Injuries sustained while committing a crime or felony. 4.2.9 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.

4.2.10 Durable and disposable medical supplies (e.g. crutches, syringes contact lenses). 4.2.11 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.

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

be applicable) as well as Worker’s Compensation Plan and SOCSO. 4.2.13 Circumcision

PMCARE SDN BHD



CHAPTER 1


15

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).

PMCARE SDN BHD


CHAPTER 5


5.0 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 RM20 Only members with maternity coverage. Look for “M” at the plan limit description on the membership card.

Antenatal – ultrasound scan RM20

Antenatal – urine RM15

Blood withdrawal for 1x RM10

Chest X-ray RM30

Circumcision RM80 Ritual circumcision for members with coverage.

Consultation RM10 – RM15 Including referral letter

Ear – syringing/toilet RM 10 - RM 15

ECG RM30

FB removal RM50-RM80

Injection RM10-RM35 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 New license RM50 Renew license RM30

Med Exam – Pre employment RM50 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 RM35

Paraphymosis release RM35

Panphymosis RM50

RBS (Random Blood Sugar) RM10

STO RM5

Urine dipstick RM10

PMCARE SDN BHD


CHAPTER 5


Item Recommended charges

Remarks

I & D Abscess RM30 – RM50

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

Excision of cyst/ganglion RM50 – RM100

Toilet & Suturing RM5 per stitch

Removal of foreign body (Ear/nose/ others)

RM50 – RM80

Dressing RM15 – RM25

Intra-articular injection RM30 – RM70

Infra red Not covered

Aerochamber Not covered

Sonotron Not covered

Ultrasound Scan Not covered Cover only for antenatal scan.

Referral letter fee Not covered

Registration fee Not covered

Disposable (dispensed) Not covered

PMCARE SDN BHD


CHAPTER 6


6.0 IMMUNISATION CHARGES

Age Immunization Recommended

charges

At birth BCG RM50 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) RM135

3 months Hepatitis B (3rd dose) RM30 3 months Diphtheria, Pertusis, Tetanus (DPT) and Polio

with HiB (2nd dose) RM135

5 months Hepatitis B (Booster dose) RM30 5 months Diphtheria, Pertusis, Tetanus (DPT) and Polio

with HiB (3rd dose) RM135

1 year MMR 1st dose RM90 1 ½ years 1st Booster - Diphtheria, Tetanus (DT), Polio RM135 5 – 7 years 2nd Booster - Diphtheria, Tetanus (DT) RM135 5 – 7 years MMR (Booster dose) RM90 15 years Tetanus Toxoid Booster RM25 All age in Sabah & Sarawak

Japanese Encephalitis RM100-RM150

Overseas Immunization requires letter of authorization from HR

Vaccination Product name Charges

Typhoid Typherix RM55 Vivotif berna (oral) RM60 Meningococcal A&C YW mencevax RM130 Malaria prophylaxis Lariam RM120 Yellow fever RM250

Injection charges Recommended charges

Ampicilline RM20

Bricanyl SQ RM20

Buscopan IM RM15

Chlorpheniramine / Piriton RM15

Dexamethazone RM15

Dimenhydrinate / Stemetil / Maxolon RM15

Gentamicin RM15

Lignocain 1cc RM5

Lincomycin 1cc RM20

Neurobion RM20

Prednisolone / Hydrocortisone RM15

Rocephine 250mg RM40

Triamcinolone / Diprospan RM30 per c.c

Voltaren IM RM20

PMCARE SDN BHD


CHAPTER 7


7.0 DIAGNOSTIC INVESTIGATION

7.1 The Necessity Of A Diagnostic Test

7.1.1 Kindly be reminded that a diagnostic test should not be done at the patient’s request or as a screening exercise.

7.1.2 All too often in the clinical setting patients ask their provider to bypass the most fundamental of all diagnostic tools, the history and physical examination, and advance to the ordering of laboratory testing in a misguided effort to reassure about their health status.

7.1.3 Providers must take responsibilities for conveying their false impressions that laboratory test somehow has magic power by them to detect diseases.

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

7.2 Filling In Your Clinical Diagnostic Request Form

7.2.1 Please ensure that the patient is indeed a PMCare member eligible for

the required test in accordance with your practice panel ship.

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

Example: MOHD MARZUQ BIN IMRAN M-M-601325-03-1231-I 7.2.3 Write in your CLINIC NAME and CLINIC CODE preferably as:

EXAMPLE: KLINIK ABCDEFG PMCare X12345 (clinic stamp) 7.2.4 Tick at the “EMPLOYER” box.

(Please refer to sample for Pantai Premier Diagnostic Form)

PMCARE SDN BHD


CHAPTER 7


Sample for Pantai Premier Pathology (PPP) Diagnostic Request Form

7.3 Communicating With Pantai Premier Pathology (PPP)

7.3.1 Inform the nearest PPP’s service office for the specimen collection. 7.3.2 Your specimen will be collected and within 1-5 days the lab report will

be delivered to you at your clinic.

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

7.4 Making A Laboratory Investigation Claim For Manual Submission

7.4.1 Pantai Premier Pathology will bill PMCare directly for the diagnostic

tests. Therefore, please do not bill PMCare. 7.4.2 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


7.4.3 This charge should be written in the column provided for lab test charges in GP Visit and Consent Form.

7.4.4 Please write in the Lab Number provided on the Lab Report by Pantai Premier Pathology (PPP) on to the GP Visit and Consent Form in the Lab (test) Column (manual or the Mediline™ equivalent) as shown below.

Sample on how to write your Lab number into the Manual GP Visit and Consent Form

7.5 Making A Laboratory Investigation Claim For Your Services

Submission of a laboratory investigation claim is either through a GP Visit and Consent Form 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 manual GP Visit and Consent Form. If you are using Pantai Premier laboratory services, please note the Lab No. If we do 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 1.10)

- Chapter 9 - Making A Laboratory Investigation Claim For Mediline™ Submission, (Clause 9.2)

Write your Lab No. at this column

PMCARE SDN BHD


CHAPTER 8


8.0 CLAIMS SUBMISSION

8.1 Mediline™ Claims

Please ensure that the GP Visit and Consent Form 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.

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 3th of the service date. PMCare will not be able to reimburse claims received after the deadline that is 3 days after the service date.

8.2 Submission of Mediline™ GP Invoicing Listing

All panel clinics are required to submit to us Mediline™ GP Invoicing Listing on a weekly, fortnightly or at least monthly basis. The listing must be duly signed by your clinic’s authorized signatory and stamped with your clinic’s stamp and mailed or couriered to the Claims Department of PMCare Sdn Bhd.

For Indah Water Konsortium (IWK) Closed Panel Clinics Your clinic is required to submit the Indah Water Konsortium (IWK) Clinic Visitation Form together with the Mediline™ GP Invoicing Listing.


- Chapter 1 - GP Claims Submission (Clause 1.15) - Chapter 1 - Submission Deadline (Clause 1.16) - Chapter 9 - Guidelines For Mediline™ Claim Submission

PMCARE SDN BHD


CHAPTER 9


9.0 GUIDELINES FOR MEDILINE™ CLAIM SUBMISSION

9.1 Steps on Submission of Claims

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.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 guest2008 as password to avoid corrupting your claim record and is not meant for actual claim submission.

PMCARE SDN BHD


CHAPTER 9


Step 2 – Patient Verification Screen

Verify your patients, either 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.

If the system states the patient to be an Invalid Member but the membership card is still valid, please contact our Provider Network Executives (during office hour) or our Careline (after office hour) to confirm on the validity.

PMCARE SDN BHD


CHAPTER 9


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 3 days from the service date.

PMCARE SDN BHD


CHAPTER 9


Step 4 – Patient Information Screen: How To Submit Your Claims

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

4.1 Key in the visit date and visit time (based on Service Time).

PMCARE SDN BHD


CHAPTER 9


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.

4.3 For Other Diagnosis, type in the diagnosis in the “Search Diagnosis”

box and click “Add Diagnosis” button. The chosen diagnosis will appear in the selected area.

PMCARE SDN BHD


CHAPTER 9


4.4 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.

4.5 MC Days. Please enter 0 if no MC is issued.

4.6 To save, click “Save” button to continue with the next submission. To check again this claim, go to “Pending Submission” and click at the claim’s row. The Patient Information screen will appear again.

4.7 To submit this claim straight away, click “Submit”. The claim will be

transmitted into PMCare server.

PMCARE SDN BHD


CHAPTER 9


Step 5 – Report:

5.1 To view you summary of claims by all clients or segregated into

companies, click “Claims Information” or “Summary by Company” or “Claim Status” 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”.

PMCARE SDN BHD


CHAPTER 9


5.2 To generate your invoice, click at “Invoice” and “Invoicing”. You need

to key in the “start date”, “end date” to “view invoices”. Please bill us using Mediline™ GP Invoicing Listing by courier or mail.

Note: After submitting your claims to us through Mediline™, you no longer need to send your GP Visit and Consent Form (formerly known as GP Claim Form) to us. For cases like the ‘system down’ and ‘terminated Member’ but still valid at the time of service date, please contact our Provider Network Executives or Careline for assistance.

PMCARE SDN BHD


CHAPTER 9


9.2 Making A Laboratory Investigation Claim For Mediline™ Submission

9.2.1 Check the “Others (Diagnostic procedures, lab tests)” at the check

box. 9.2.2 Write the Lab Number provided in the provided text box.

Sample on how to write your Lab number


- Chapter 1 - Diagnostic Investigation (Clause 1.10) - Chapter 7 - Diagnostic Investigation

Key in the Lab No. here

PMCARE SDN BHD


CHAPTER 10


10.0 PMCARE WORKING GUIDELINES: SUMMARY

10.1 PMCare Sticker – Please display your sticker, be it Closed or Open Panel,

prominently as to be seen clearly by the members.

10.2 Verify your Patient – Each Member may present with a valid PMCare 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 PMR Instant Verification System or Internet (Mediline™). The burden of

proof to verify the validity and eligibility of the member lies on the clinic on providing

the service. Should you have problem or doubt over the verification process, please

contact us through our 24 hours Careline at 1-300-88-6868.

10.3 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 and let this be known to your patient. 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.

10.4 Mediline™ - For submission through the Mediline™ please ensure that all

information is provided promptly. Please ensure that all details are entered correctly.

10.5 GP Claim Submission – Submission through Mediline™ should be done daily,

preferably just after the service has been rendered. Claims over three (3) days from

the date of service shall be barred. Claims on persons not eligible for medical

services, incomplete information and wrong clinic code will be rejected. Note that it is

your duty to secure consent for the release of treatment information to us for claims

processing.

10.6 Internet Connection – To register your connection with our Mediline™, please

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

10.7 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.

10.8 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.

10.9 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.

10.10 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.

PMCARE SDN BHD


CHAPTER 11


APPENDIX 1

DIRECTORY FOR MEDICAL DEPARTMENT

STAFF

PMCARE SDN BHD


CHAPTER 11


DIRECTORY FOR MEDICAL DEPARTMENT STAFF

No. Name Telephone E-Mail

1. Dr. Mohd Helmi Ismail Medical Director

03-8026 6861 [email protected]

2. Dr. Armijn Fansuri Mustapa Assistant Medical Director


3. Dr. Sivaghami Palaniveloo Assistant Medical Director – Medical Services


4. Rozita Mohamed Noor Assistant Manager – Medical Management


PROVIDER NETWORK – HOSPITAL & SPECIALIST UNIT

5. Azni Abu Bakar Provider Network Sr. Executive


6. Siti Asmah Ahmad Hamdan Provider Network Executive


7. Faezah Ibrahim Provider Network Executive


8. Noor Suhaida Shariff Provider Network Jr. Executive


9. Izyan Najla Obaidellah Provider Network Jr. Executive


10. Norwatilah Shood Provider Network Sr. Clerk


11. Noor Faliza Ismail Provider Network Clerk


PROVIDER NETWORK – GP CLINIC UNIT

12. Wan Zaimah Wan Zahari Provider Network Executive


13. Azlina Misro Provider Network Sr. Executive


14. Mohd Akmal Md. Alashari Provider Network Executive


15. Noor Ainn Zaidi Provider Network Executive


16. Sarenawaty Md Reduan Provider Network Sr. Clerk


17. Mazura Abdul Hamid Provider Network Sr. Clerk


18. Masykurah Muhamad Abdullah Provider Network Clerk


19. Rosilawati Shafee Provider Network Clerk


MEDICAL MANAGEMENT UNIT

20. S. Mahandrran Medical Management Assistant Manager


21. Zaini Che Ghani Medical Management Sr. Executive


22. Khalidah Kailan Medical Management Executive


23. Josniha Joehari Medical Management Executive


24. Syazana Abd Azis Medical Management Sr. Clerk


35

APPENDIX 2

REFERRAL LETTER TO SPECIALIST FORM

36

REFERRAL LETTER TO SPECIALIST

Date of Referral Refered to (Consultant/Speciality/Hospital):

Referral for

Outpatient Inpatient

PATIENT INFORMATION

Patient’s Name

Patient’s Membership ID

Name of Employer

NRIC/Birth Certificate No. Date of Birth

MEDICAL HISTORY

Past Medical History

Current drugs or medication

REASON FOR REFERRAL

Provisional Diagnosis

Presenting Symptoms

Blood Pressure

Body Temperature

Pulse

Since when? Day: Month: Year:

Please indicate (√) if the referred illness or treatment is/are

MVA related Yes No Date of accident

Chronic Yes No

Cosmetic Yes No

Pregnancy related Yes No

Fertility related Yes No

Congenital Yes No

Work related Yes No

Psychological related Yes No

Signature and Referring Practitioner’s stamp

PMCARE SDN BHD (458443-P) No.1, Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia. General Line: 03-8026 6888 Careline: 1-300-88-6868 Careline Centre Fax: 03-8023 9999 E-mail : [email protected]

OPS/ GL-DA-25, Rev 0, Eff Date: 30/04/2012 Page 36 of 47 25_Referral Letter To Specialist_ Rev 0

37

THANK YOU

FOR YOUR

EXCELLENT SERVICE

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