Yes, it is necessary to provide a Valid ID during availment for the coordinators/customer care to validate that the person availing is the one entitled for the said benefits.
All the availments of our members are diagnosis- based and thoroughly evaluated by our medical team prior to giving approval. We are also following the Clinical Practice Guidelines wherein we do a ladderized-type of approval. Example: If a member suffers from UTI, the initial test that needs to be done is urinalysis. If the doctor requested an ultrasound as an initial test, customer care people will advise you to have urinalysis first.
Members may only avail from accredited doctors at accredited hospital and clinics, however, if there is no accredited provider in the area, a member may reimburse for his/her availment up to 100% based on 1COOPHealth rate of expense. If there is an accredited provider in the area but the member wishes to avail the services of a non-accredited provider still reimbursement is allowable up to 80% of 1COOPHealth rate only subject to remaining limit.
For inquiries on benefit coverage, you may call any of our Customer Care Hotlines. Your medical details and needed procedure will be assessed if coverable (or otherwise) in your health plan.
All 1COOPHealth enrollees are entitled to an APE after 3 months of enrollment. A request for an APE schedule will be needed 5 days prior to actual availment. The request for APE should be coursed thru the mother cooperative for proper endorsement to 1COOPHealth . This can be done thru email at firstname.lastname@example.org.
To reimburse, you need to submit the following documents:
a. Original Official Receipt/s, including the Statement of Account (SOA) and its Charge Slips/Itemized billing.
b. Clinical Abstract if surgical intervention was performed and its hispathological report.
c. Operative Record of the case/treatment or admission/ discharge record duly signed by the attending Physician.
It is possible, provided that the patient will have to shoulder the corresponding Room and Board excess fees, incremental costs of laboratory and procedures done, and the excess in Professional Fees and 30% incremental cost for other charges.
Submit a notarized affidavit of lost together with the accomplished ID Replacement Form and pay P250.00 for card replacement fee
In this case, you may choose one of the following options:
a. Occupy a lower room category and pay no incremental charges.
b. Occupy an available room one category higher than what is entitled and pay only the room and board excess. You must transfer to your designated room category once the room becomes available; otherwise, you will pay all incremental charges from the second day of confinement.
c. Or you may transfer to another accredited hospital if it is a non-emergency case.
Any and all illnesses proven to be related to or is a complication of a certain illness shall share the same Maximum Benefit Limit (MBL).
You will have to shoulder the PhilHealth cost equivalent upon discharge.
1COOPHealth will release the HMO Card of new members 2-3 weeks after we receive the list of enrollment. We will provide a certificate of coverage together with one valid ID that you will present to the clinic or hospital upon availment in the absence of your HMO card.
If the requirements are complete, the process of reimbursement and death claim is 30 working days maximum from the date of receipt of all the documents. All the requirements for reimbursement must be sent to 1CoopHealth within 30 days after the date of availment/discharge/death, otherwise it will be forfeited.
There are forms provided for each claim such as medical reimbursement, death claim, and HIB benefit. Appropriate requirements are stated in each form. It is important that all the necessary information is accomplished to process your claim and all the documents required are submitted.
We can send the refund of claims to your main branch.
1CoopHealth can only reimburse up to 80% based on 1COOPHealth rates of the hospital bill and Professional Fees.
Patients don’t need to give any payment before admission as long as there is still remaining benefit limit on his/her account. You just need to present your 1COOPHealth membership ID.
You don’t need to request an LOA from 1COOPHealth before availment unless it is APE. Accredited providers will coordinate with 1COOPHealth for the approval of availment and issuance of LOA.
All hospitals have an HMO Department. However, we also have coordinators in some hospitals where members may get their LOAs.
We are diagnosis-based in covering your availments. Just like other HMOs, 1COOPHealth has certain exclusions.
(Ex: pregnancy related cases, take home medicines, personal items, diseases that are declared epidemic or pandemic by the Department of Health, World Health Organization or any recognized health authority)
Note: All Pre-existing conditions/illnesses are covered after 1 year of contestability period or upon renewal of plan and/or as stipulated in your contract.