How to Access Services and Reimburse Claims

An emergency condition shall mean the sudden and unexpected onset of illness or injury which, at the time of occurrence, reasonably appears to have the potential of causing disability or death, or which requires immediate alleviation of severe pain and discomfort. These illnesses or injuries require urgent medical or surgical care which the enrollee secures immediately after the onset or as soon as the care may be made available but, in any case, no later than 24 hours after the onset. Heart attacks, cardiovascular accidents, poisonings, loss of consciousness or respiration and convulsions are examples of emergency conditions.

For such conditions, Member may proceed to the emergency room of the nearest hospital or clinic whether accredited or non-accredited.

1. Maxicare-Affiliated Hospitals
• As soon as the necessary medical treatment is rendered and that Member is stabilized, the ER staff will ask for Member’s Maxicare card and a supporting ID for membership validation. If validation is successful, a Letter of Eligibility (LOE) will be generated. If necessary, the ER staff will secure Maxicare’s approval for Member’s emergency care availment.
2. Non Maxicare-Affiliated Hospitals
• After treatment at the Emergency Room, all necessary receipts and clinical records must be secured for processing of claim/s for reimbursement.
• Properly-accomplished Maxicare Claim for Reimbursement Form and Medical Certificate must be submitted to Maxicare Head Office, thru the Claims Department, within ten (10) days from date of hospital discharge.

In an emergency confinement where Member’s room entitlement is not available, room upgrading is allowed. However, upgrading is applied only to the next higher room accommodation. In this case, Member will not shoulder the excess charges, i.e., the room rate difference and incremental costs on the first 24 hours from actual time of confinement.

On the other hand, should room upgrading extend beyond specified period, all excess charges will be under Member’s accountability and should be settled directly with the hospital’s Billing Section upon hospital discharge.

• Recommendation or order for hospital admission, whether elective or emergency in nature, must come from any Maxicare-affiliated physician in the same hospital where admission will be made.
• Once proper hospital admitting order is secured, Member must present his/her Maxicare card, together with a supporting valid ID, to the hospital’s Admitting section where his/her Maxicare card will be swiped for membership validation. A Letter of Eligibility (LOE) will be generated once validation is successful. As soon as the LOE is generated, the hospital staff will facilitate admission based on Member’s benefit and room limits reflected on the LOE.
• Our Customer Care Department will assess coverability of Member’s hospital availment. If coverage is determined, a Letter of Authorization (LOA) will be issued by our Roving Customer Care Specialist to the hospital where Member is admitted.
• Room upgrading during an elective confinement can also be allowed. However, the difference in the room-and-board, doctor’s professional fees and incremental costs incurred shall be charged to and settled directly by the member upon hospital discharge.
• Our Roving Customer Care Specialist will visit confined Member within 48 hours from Member’s date of admission. Hospital coverage, limitations and related requirements, such as filing of Philhealth, will be discussed by our Roving Customer Care Specialist with the Member.
• Member is required prompt filing of his/her Philhealth Sickness Benefit Claim which should be forwarded to the hospital’s Philhealth Section prior to hospital discharge. If Member fails to file his/her Philhealth claim, Member will be required to settle in full the Philhealth cost before hospital discharge.

• Prior to availment, Member is required to present his/her Maxicare membership card, supported by any valid ID card bearing his/her signature and photo. A Letter of Eligibility (LOE) will be generated after a successful membership validation.
• Once diagnosed for any ailment, medical care will be rendered by:
• Maxicare Retainer Physician at Company Sites
• Maxicare Primary Care Physician at any Maxicare Primary Care Center
• Maxicare Coordinator at any Maxicare-accredited hospital or clinic

If member’s medical condition requires consultation with another specialist, appropriate referral will be made by the Maxicare Retainer Physician, Coordinator or Customer Care Representative.