An Emergency Condition is an accidental injury, a life threatening or a sudden and unexpected onset of a condition in which reasonably appears to have the potential of causing immediate disability or death, or which requires the immediate alleviation of pain and discomfort. HMO shall depend on the concurrence of the attending ER physician to determine whether a case is emergency in nature or not.
A hospital with an existing and valid accreditation contract where a Member can seek medical services. It shall also mean any of the hospitals named in such list as provider may from time to time prepare and distribute to Members, and with which Medical Coordinator has made arrangements for the provision of medical services to Members pursuant to this agreement.
Such duly licensed out-patient medical and healthcare facility may establish or designate for the purpose of providing out-patient care to Members. It shall also mean a private medical facility which is capable of providing medical, diagnostic and therapeutic facilities, and with which HMO provider has an existing service agreement
A group of medical practitioners and other allied health professionals who are affiliated with provider and duly authorized to carry out the delivery of the required medical services to all Members.
A duly licensed physician or specialist affiliated with provider and named in the list as affiliated doctors with whom provider has made arrangements to provide the required services under this Agreement.
This Service Agreement executed by and between the provider and the client containing the effective date, benefits, coverage, claims and member satisfaction provisions, limitations and exclusion of benefits, mode of payment of membership fees, termination of coverage and other matters relevant to the relationship between the Member and Provider. The application for Membership duly submitted by the accepted Member, and the Provider Membership Card, form part of the Service Agreement, together with any and all endorsements which may be incorporated thereto.
This is defined as therapeutic practices which are not currently considered an integral part of conventional allopathic medical practice. Alternative medicines include, but are not limited to the following disciplines: folk medicine, herbal medicine, diet fads, homeopathy, faith healing, new age healing, chiropractic, acupuncture, naturopathy, massage, and music therapy.
It is the act of some physicians and other health professionals duly affiliated by Provider to charge members for the difference between their desired higher professional fees and the agreed standard professional fees for specific medical services.
A person is said to be confined or hospitalized if he is admitted in a hospital as a registered bed patient for at least twelve (12) hours
The restoration of a person’s ability to function as normally as possible after a disabling illness or injury.
Care furnished primarily to provide room and board (which may or may not include nursing care, training, personal hygiene, and other forms of self or supervisory care); or care furnished to a person who is physically or mentally disabled or both; and
Who is not under any specific medical, surgical or psychiatric treatment to reduce the existing disability to the extent medically necessary to enable the patient to live outside an institution providing such care; or
When despite such treatment, there is no reasonable possibility that the disability will be reduced or diminished.
Care provided in the patient’s home when in-patient care is not medically necessary
Any device, medical treatment, supply or procedure whose safety and efficacy has not been established and proven is considered experimental/investigational (unproven) and is excluded from the coverage.
The hospitalization which includes accommodations, medicines and supplies and surgery whenever medically necessary, furnished to a registered bed patient and provided by a duly licensed hospital and are regularly included in its service and procedures.
A medical procedure defined as:
Requires the specialized skills from specialized personnel; and
Is sanctioned and recognized as a significant medical update and part of the standard clinical practice guidelines by the corresponding clinical and academic society or association responsible for certifying practicing specialist physicians.
A duly licensed physician medical practitioner as Provider may designate in an Affiliated Hospital to direct and supervise the provision of medical services to Members in that particular hospital with whom Member may also seek medical consultation, and from whom the Member may request for prescription, referrals to specialist, request for laboratory examination and hospitalization arrangement.
The maximum liability that Provider shall assume illness/injury per year on a certain Member, not including Annual Check-Ups (ACU) and consultations. In other words, the In-Patient Benefits (PF, HB, ER charges) and Outpatient Routine Diagnostic and Therapeutic procedures done within the one-year term of the Agreement with respect to any particular illness/injury shall be charged against the MBL. MBL is replenished upon renewal.
A medical service which is consistent with the diagnosis and customary medical treatment of the condition,
b. in accordance with the standards of good medical practice, c. not for the convenience of the Member of the Affiliated Physician, and d. performed in the least costly manner required by the medical condition.
Member shall mean an individual who: applied to Provider for membership in its healthcare program,
was accepted by Provider as member after complying with all the requirements of the membership,
is entitled to the benefits of Membership as stated in this Agreement, and has not forfeited his status as such Member by termination, lapsation, non-payment premium, voluntary abandonment, exhaustion of benefits or some other cause.
The card issued by Provider to a Member containing the latter’s name and signature, ID reference number, and other matters relevant to Membership.
An illness or condition shall be considered pre existing if, prior to the effective date of the member’s health coverage (Membership Agreement) or prior to the approval date:
any professional advice or treatment was given for such illness or condition;
such illness or condition was in any way evident to the member or upon medical examination in connection with the member’s application; or the pathogenesis of such illness or condition has started whether or not the member is aware of such illness.
The following conditions, among others, when occurring during the first year of coverage after the Effective Date, are considered Pre-existing:
- cancer or tumor or neoplasms;
- ear-nose–throat conditions requiring surgery;
- Hyphothyroidism / hyperthyroidism/goiter;
- cataracts and glaucoma;
- cirrhosis of the liver;
- anal fistulae;
- calculi of the urinary system;
gastric or duodenal ulcer;
- hallux valgus;
- diabetes mellitus;
- collagen diseases
- cardiovascular diseases.
Professional fees of Non- Affiliated physicians for services rendered to Provider Members which do not exceed the standardized professional fees/terms of the Provider Affiliated Physicians/Specialists where the services were rendered. Reasonable charges are usually determined by the lowest limit of the actual charge, the prevailing charge in the locality, the physicians customary charge, or the carrier’s usual payment for comparable services.
A condition/disorder/disease entity is said to be related if it is associated with the particular diagnosis in question either as a direct symptom/sign, a risk factor, an underlying cause, a part of a syndrome, or a complication.
The type of hospital room and board pre – assigned by Provider to the Member based on the plan enrolled in.
For inquiries on your benefit coverage, you can call our Call Center hotlines. Our Call Center Specialists will ask for your medical details to assess coverage of your availment based on your program.
For your annual check-up (ACU) benefit, you would need to request for a schedule of your ACU prior to actual availment. This can be done through any of our ACU Representatives via phone call or email (please refer to our ACU Team’s contact details through our website).
If the Member fails to file the Philhealth benefit Claim form, he will have to pay for the Philhealth cost equivalent upon discharge.
- The Member has to submit the following:
- Duly accomplished Claim for Reimbursement form
- Original official receipts of all hospital bills, including the statement of account and its charge slips
- Clinical abstract of the case, if surgical intervention was performed and its histopathological report
- Operative record of the case/treatment or admission/discharge record duly signed by attending physician
- All pertinent documents to support confinement
Reimbursement will be released through checks within 30 working days upon the receipt of necessary documents at Provider’s Head Office, provided that all documents and requirements are complete.
Yes, and to avoid this, please coordinate with our Customer Care Department before each availment in order for them to make arrangements with a doctor who does not charge extra fees.
This is possible, provided that the patient will have to shoulder the room and board excess fees, the incremental costs (lab fees, procedures done, etc.) and the excess professional fees.
You have to fill up the Statement of Lost ID Card and submit it to the OPTIONS Head Office together with P200 as payment for the lost ID Card. Your new ID card will be issued within 7 working days from the date the necessary documents were forwarded to OPTIONS Head Office, provided that all requirements are complete.If you wish to avail of OPTIONS services while your card has not arrived, call the Customer Care Hotline first before seeking consultation. In an emergency, instruct Companion to contact OPTIONS.
Our Call Center operates 24/7 and is manned by our Call Center Specialists who are highly trained to assist you in any of your medical availments.
Our Primary Care Centers and Coordinators’ clinics are open from Monday to Saturday. Our coordinators’ contact details and clinic schedules are listed in our website’s Accredited Providers page.