PMCARE SDN BHD TERMS AND CONDITIONS FOR PMCARE – CIMB BANK

APPENDIX I

PMCARE SDN BHD TERMS AND CONDITIONS FOR PMCARE – CIMB BANK BERHAD CLOSED PANEL OF GENERAL PRACTITIONER CLINICS

PMCARE SDN BHD TERMS AND CONDITIONS OF PMCARE – CIMB CLOSED PANEL OF GP CLINICS 1.0

PANELSHIP Your clinic shall be appointed to our PMCare - CIMB Bank Berhad Closed Panel of GP Clinics (hereafter referred to as PMCare – CIMB 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 above stated 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 - CIMB Closed Panel of GP clinic, you are required to have Internet ready in the computer system to enable you to implement our Mediline system application before the 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 - CIMB Closed Panel of GP Clinics sticker at a prominent place in front of your clinic.

Effective Date: 13/09/07, Revision 0

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PROVISION OF SERVICES – MEDICAL ATTENTION, TREATMENT AND ANCILLIARIES TO PMCARE MEMBERS You shall provide services only to valid PMCare – CIMB 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 – CIMB program.

9.0

MAINTENANCE OF RECORDS AND CONSENT Your clinic shall maintain record of every PMCare – CIMB 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 the verification purpose.

10.0

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

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

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.

12.2

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 may be required to submit Medical or Laboratory Report together with your GP Visit and Consent Form.


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PMCARE SDN BHD TERMS AND CONDITIONS OF PMCARE – CIMB CLOSED PANEL OF GP CLINICS GP Visit and Consent Forms that are incomplete or incorrect or illegible will not be accepted or payable. 13.0

QUERIED CLAIMS PMCare reserves the right to query your claims for: i. ii.

Exceptionally high charges as compared to industry benchmarks; 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. 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. ii. iii. iv.

Treatment provided to non-valid member; Exclusion items; and Medical examination conducted without proper authorization; 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.


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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 – CIMB 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 AND BUSINESS ADDRESS

NAME

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 duly certified true copy by the Commissioner of Oath. 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.


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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 CIMB 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 – CIMB Closed 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 – CIMB Closed Panel of GP Clinics: i. ii. iii.

Acceptance of Letter of Offer for appointment (For CIMB Panel, Letter of Offer for Appointment); Display PMCare – CIMB Closed Panel of GP Clinic Logo Connected to Mediline


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APPENDIX II

PMCARE SDN BHD

WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GENERAL PRACTITIONER CLINICS 01/2007

TABLE OF CONTENT Chapter 1 - PMCARE WORKING ARRANGEMENT FOR GP CLINIC 1.1 Introduction Panelship 1.2 1.3 Principal Doctor 1.4 Clinic Address 1.5 Clinic Code 1.6 Installation of PMCare Mediline System 1.7 Clinic Identification Modes of Identification of PMCare Member 1.8 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

PAGE

1 1 1 1 1 2 2 3 3 4 4 4 5 5 5 6 6

Chapter 2 2.1 2.2 2.3

PMCare – CIMB Closed Panel of GP Clinic Sticker PMCare – CIMB Membership Cards 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 Filling in Your Clinical Diagnostic Request Form 5.2 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 - CLAIMS SUBMISSION 6.1 Mediline Claims 6.2 Returned or Queried Claims

7 7 8–9 10 - 11 12

13 13 – 14 14 14 – 15 15

16 16

Chapter 7 - GUIDELINES FOR MEDILINE SUBMISSION

17 – 25

Chapter 8 - PMCARE GUIDELINES: SUMMARY

26 – 27

Chapter 9 - DIRECTORY FOR MEDICAL DEPARTMENT STAFF

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB 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 – CIMB 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 – CIMB 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 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 as our panel is as specified in the Letter of Offer of Appointment in the Terms and Conditions. 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 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 help administer the business arrangement between clinic and PMCare.


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INSTALLATION OF 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. Please use Internet Explorer version 5.0 and above or Netscape Navigator version 6.0 and above to proceed to 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.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 Submission (Chapter 7). If you have further queries, please call us for assistance.

1.7

CLINIC IDENTIFICATION 1.7.1 PMCare – CIMB Closed Panel of GP Clinic Sticker To facilitate our Members identify and access our panel clinics, all appointed clinics shall be identified by PMCare – CIMB Closed Panel of GP Clinics sticker. PMCare – CIMB Closed Panel of GP Clinics sticker should be displayed at all time during the term of appointment. The PMCare – CIMB 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 2.1) for sample of our existing PMCare – CIMB Closed Panel of GP Clinics sticker. 1.7.2 How to Display Sticker Please display the PMCare – CIMB 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.


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MODES OF IDENTIFICATION OF PMCARE MEMBER 1.8.1 Types Of Identification (ID) Every PMCare – CIMB Member is given a CIMB Membership Identification “ID” and is required to produce the ID whenever requesting for medical attention or service at the panel clinics. Clinic must use CIMB Employee number in verification of patient. 1.8.2 Verification of Member When a Member seeks for medical services at your clinic, kindly request for the PMCare – CIMB 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. 1.8.3 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 the Employee number. 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 Submission (Chapter 7). 1.8.4

1.9

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

MEDICAL RECORD Your clinic shall maintain records of every PMCare – CIMB 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.


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 1 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 the records for the verification purpose. 1.10

DIAGNOSTIC INVESTIGATION In the course of treatment to our Member, it require the Member to undergo diagnostic investigation must not be general screening in investigation must assist you in making diagnosis

may be necessary for you to investigation. The diagnostic nature and the results of the 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 6) 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 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. For maternity cases, referral to specialist care can only be done for patient in cases of complications.


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EXCLUSIONS Member healthcare benefit under PMCare – CIMB 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 – CIMB 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 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 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 7.2.1 to 7.2.2). Please provide the following details: 1.15.1.1 1.15.1.2

Medical condition and/or diagnosis and treatment given; Medication – describe prescription(s), drug name, dosage, amount dispensed and itemized cost. 1.15.1.3 Injection – give drug name, dosage and route of delivery; 1.15.1.4 Nebulizer – give the drug (nebulizer fluid) name(s), number of time of nebulizer given. 1.15.1.5 Toilet and suturing – indicate the number of sutures used; 1.15.1.6 Dressing – indicate the type of dressing done. e.g. Eusol dressing. 1.15.1.7 Minor surgery – indicate the nature of surgery. e.g. excision of ganglion. 1.15.1.8 Other treatment procedures such as removal of foreign body, ear syringing, suction. Indicate the type of procedure done with brief description. 1.15.1.9 X-Ray – indicate site and view(s) and attach a copy of the report. 1.15.1.10 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;


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 1 1.15.1.11 Medical (sick) leave certificate – please provide MC to deserving case and indicate number of days clearly; 1.15.1.12 Medical Examination – indicate the type of examination and attach copy of the employer’s or PMCare authorization letter with a copy of the lab result. 1.15.1.13 Please indicate your clinic code at the GP Visit and Consent Form as a reference. 1.16

SUBMISSION DEADLINE

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 6 – Claims Submission (Page 16) - Chapter 7 – Guidelines For Mediline Claim Submission (Page 17) 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 Staff of Medical Department). Your email address would be greatly facilitating communication between both parties. You are encouraged to e-mail your inquiry or feedback to us. Remember to quote your clinic code each time communicating with us.


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 2 2.1 PMCARE – CIMB CLOSED PANEL OF GP CLINIC STICKER

2.2 PMCARE – CIMB MEMBERSHIP CARD


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 2 2.3 LIST OF EXCLUSIONS ITEMS The following is the list of conditions NOT COVERED by CIMB: 2.3.1

Non-medical services provided by a hospital such as radio, television, telephone, fax or similar facilities.

2.3.2

Cosmetic surgery, cosmetic treatment, eye refraction, contact lens or any procedures to correct / alter refractive errors including prescription of glasses and contact lens and refractive surgery using laser or any other means or device, the acquisitions of prosthetic such as artificial limbs, and hearing aids except as necessitated by injuries occurring wholly during the period of coverage.

2.3.3

Dental care treatment (unless covered by the dental package), filling, extractions including removal of impacted tooth and general dental care except dental operation resulting from an injury sustained by the Member in any accident.

2.3.4

Mental illness and psychiatric disorders, self-inflicted injuries or attempted suicide, consequences of alcohol abuse, drug addiction, and treatment to improve the psychological, mental or emotional well being of the person covered.

2.3.5

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

2.3.6

Investigation and treatment (of condition) related to pregnancy, child birth (including surgical delivery), miscarriage, abortion and prenatal and postnatal care (unless covered by the maternity package).

2.3.7

Third party requested Medical Examinations including pre-employment, insurance and routine physical examinations, tests not incidental to treatment or diagnosis of a covered disability, or any treatment which is not medically necessary including preventive treatment (including any circumcision whether or not related to illness or infection, voluntary sterilisation of either sex such as castration, vasectomy and tubectomy), preventive medicine (including elective adult immunizations), and treatment for obesity, weight reduction or weight improvement (unless preventive programs implemented by PMCare or officially directed by CIMB).

2.3.8

Sickness or injury arising from racing of any kind (except foot racing), sky diving, scuba diving and illegal activities; flying except as an ordinary fare paying passenger on a regular public air service or charter plane.

2.3.9 Treatment of sexually transmitted diseases. 2.3.10 Injuries sustained while committing a crime or felony.


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 2 2.3.13 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 or as a result of natural disaster. 2.3.14 Durable and disposable medical supplies (e.g. crutches, syringes). 2.3.15 Non-therapeutic dietary supplements (including vitamins), appetite suppressants, anabolic steroids and pharmaceutical products not registered with the Ministry of Health. 2.3.16 Indemnity covered by other medical insurance (Ratable Proportion Contribution will be applicable).

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. When in doubt, please contact our Careline)


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 3 3.0 RECOMMENDED FEE SCHEDULE Item MEDICATION Antenatal - consultation Antenatal - scanning Antenatal – urine

Recommended charges Remarks All medication must be itemized individually and will be reimbursed accordingly. Supply of medication for chronic cases should be on a monthly basis. Only members with RM 20 maternity coverage. Look for RM 20 “M” at the plan limit description on the RM 15 membership card.

Blood withdrawal for 1x

RM 10

Chest X-ray

RM 30

Circumcision

RM 80

Consultation

RM 10 – RM 15

Ear – syringing/toilet

RM 10 - RM 15

ECG FB removal Injection Laboratory test Med Exam - GDL Med Exam – Pre employment

Including referral letter

RM 30 RM50-RM80 Refer to details on injection charges 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 New license RM 50 Renew license RM30 Requires letter of RM 30 authorization from HR RM10-35

Nail Avulsion

RM 60 – RM 80

Nebulizer

RM 10 - RM15

- 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


Ritual circumcision for members with coverage.

See details below.

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 3 Item I & D Abscess Excision of cyst/ganglion

Recommended charges RM 30 – RM50 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

Infra red

Not covered

Aerochamber

Not covered

Sonotron

Not covered

Scan (ultrasound)

Not covered

Referral letter

Not covered

Registration

Not covered

Disposable

Not covered


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

Cover only for antenatal scan.

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 4 4.0 IMMUNISATION CHARGES Age At birth At birth 2 months 2 months 3 months 3 months 5 months 5 months 1 year 1 ½ years 5 – 7 years 5 – 7 years 15 years

Immunization BCG Hepatitis B (1st dose) Hepatitis B (2nd dose) Diphtheria, Pertusis, Tetanus (DPT) and Polio with HiB (1st dose) Hepatitis B (3rd dose) Diphtheria, Pertusis, Tetanus (DPT) and Polio with HiB (2nd dose) Hepatitis B (Booster dose) Diphtheria, Pertusis, Tetanus (DPT) and Polio with HiB (3rd dose) MMR 1st dose 1st Booster - Diphtheria, Tetanus (DT), Polio 2nd Booster - Diphtheria, Tetanus (DT) MMR (Booster dose) Tetanus Toxoid Booster

Recommended charges RM30 RM30 RM90 RM30 RM90 RM30 RM90 RM45 RM55 RM45 RM45 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 Ampicilline Bricanyl SQ Buscopan IM Chlorpheniramine / Piriton Dexamethazone Dimenhydrinate / Stemetil / Maxolon Gentamicin Lignocain 1cc Lincomycin 1cc Neurobion Prednisolone / Hydrocortisone Rocephine 250mg Triamcinolone / Diprospan Voltaren IM


Recommended charges RM12 RM12 RM10 RM10 RM10 RM10 RM10 RM3 RM15 RM10 RM10 RM35 RM20 RM15

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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 5 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.

5.1.4

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:

5.2.3

MOHD MARZUQ BIN IMRAN M-M-10012345-I

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)


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 5 Sample for Pantai Premier Pathology (PPP) Diagnostic Request Form

Lab number Tick the “employer ” box

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

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

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 1-5 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/specimenhandling 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).


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5.4.3

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

5.4.4

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 on below.

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

dhi2002

5.5 Making A Laboratory Investigation Claim For Your Services 5.4.1

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 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 1.10 (Page 4). - Chapter 7 – Making A Laboratory Investigation Claim For Mediline Submission Clause 7.2 (Page 25).


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 6 6.0 CLAIMS SUBMISSION 6.3

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 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.

6.4

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.

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)


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 7 7.0 GUIDELINES FOR MEDILINE SUBMISSION 7.1 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.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.


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 7

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 Membership Number. 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.

Select here to verify the Dependents


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 7 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.


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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.


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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.


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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.


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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”.


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 7 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.

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 ‘system down’ and ‘terminated Member’ but still valid at the time of service date, then you are allowed to submit the GP Visit and Consent Form available under “GP Claim Form” menu with a cover letter on one of these reasons. You can print the GP Visit and Consent Form from Mediline.


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Making A Laboratory Investigation Claim For Mediline Submission 7.2.1

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.

7.2.2

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

Key in the Lab No. here

Note: Please also see - Chapter 1 – Diagnostic Investigation Clause 1.10 (Page 4) - Chapter 5 – Diagnostic Investigation (Page 13)


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PMCARE GUIDELINES: SUMMARY 8.1

PMCare – CIMB Closed Panel of GP Clinic Sticker – Please display your sticker, be it Closed or Open Panel, prominently as to be seen clearly by the members.

8.2

Verify your Patient – Each Member may present with a valid CIMB 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

GP Visit and Consent Form – For submission through the Mediline please ensure that all information is provided promptly. Please ensure that all details in the form are entered correctly.

8.5

GP Claim Submission – Submission through Mediline should be done daily, preferably just after the service has been rendered. 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.


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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.


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PMCARE SDN BHD WORKING GUIDELINES FOR PMCARE – CIMB CLOSED PANEL OF GP CLINICS CHAPTER 9 9.0 No. 1. 2.

DIRECTORY FOR MEDICAL DEPARTMENT STAFF Medical Department

Dr. Mohd Helmi Ismail Director, Medical Management Dr. Benjamin Sinappan Director, Medical Services

Telephone

E-Mail

03-8026 6861

[email protected]

03-8026 6863

[email protected]

PROVIDER NETWORK – HOSPITAL & SPECIALIST UNIT 3. 4. 5. 6. 7. 8.

Nurullydia Ahmad Provider Network Executive Tengku Muhammad Sunaidi B. Tg Ismail Provider Network Executive Syahrul Nizam Baharudin Provider Network Executive Noor Suhaida Shariff Provider Network Sr. Clerk Faezah Ibrahim Provider Network Sr. Clerk Masykurah Muhamad Abdullah Provider Network Clerk

03-8026 6874

[email protected]

03-8026 6879

[email protected]

03-8026 6871

[email protected]

03-8026 6876

[email protected]

03-8026 6875

NA

03-8026 6873

NA

03-8026 6869

[email protected]

03-8026 6866

[email protected]

03-8026 6877

[email protected]

03-8026 6864

[email protected]

03-8026 6849

NA

NA

NA

03-8026 6842

[email protected]

03-8026 6878

[email protected]

03-8026 6872

[email protected]

03-8026 6865

[email protected]

03-8026 6867

[email protected]

03-8026 6867

[email protected]

PROVIDER NETWORK – GP CLINIC UNIT 9. 10. 11. 12. 13. 14. 15.

Siti Asmah Ahmad Hamdan Provider Network Executive Nazrulsyah Firaz bin Fauzee Andylim Provider Network Executive Wan Zaimah Wan Zahari Provider Network Executive Sarenawaty Md Reduan Provider Network Sr. Clerk Mazura Abdul Hamid Provider Network Clerk Mohd Hafizee Ismail Provider Network Executive Norwatilah Shood Provider Network Clerk

MEDICAL MANAGEMENT UNIT 16. 17. 18. 19. 20.

S. Mahandrran Medical Management Sr. Executive Zaini Che Ghani Medical Management Sr. Executive Azni Abu Bakar Medical Management Executive Khairul Norziana Kamarudin Medical Management Executive Josniha Joehari Medical Management Sr. Clerk


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THANK YOU FOR YOUR EXCELLENT SERVICE

PMCARE SDN BHD TERMS AND CONDITIONS FOR PMCARE – CIMB BANK

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