Frequently Asked Questions:

Ans: 1COOPHealth is a cooperative HMO providing members access to medical services through accredited hospitals, clinics, and doctors.

Ans: You must be a member to any of our member Cooperative prior enrollment with us.

Ans: You can contact your cooperative representative to obtain the policy number. The HMO card will be distributed by 1COOPHealth to your respective cooperative where you can claim your HMO card.

Ans: Normally during your first year of enrollment, pre-existing conditions are not covered. You can have a coverage for pre-existing illnesses after 12 months of continuous membership. Accounts with at least 100 initial enrollments are entitled to Pre-Existing Condition coverage in the first day of membership.

Ans: You have the option to upgrade or downgrade your plan upon renewal of your coverage.

Ans: You can cancel your membership and request a refund from your cooperative within the first six (6) months from effective date. A Pro-rated computation of refund is based on the unused months of your membership from the time of your cancellation. No refund will be made after 6 months of membership.

Ans: You must renew your coverage within 90 days from expiration date. If you renew your policy beyond 90-day period, it will be reinstated. Upon reinstatement, a new policy number will be generated, and your application will be treated as a new enrollment. As a result, pre-existing illnesses will not be covered on the first 12 months of membership. However, the coverage for pre-existing conditions will be based on the Cooperative’s contract with 1COOPHealth.

Ans: To renew your 1COOPHealth card, simply get in touch with your cooperative representative.

Ans: Reach out to your cooperative representative for assistance. You may also register your policy number by downloading our 1COOPHealth application.

Ans: 1COOPHealth will release the HMO Card of new members 2-3 weeks after we receive the list of enrollments. We will provide a certificate of coverage and together with your valid ID and present to the clinic or hospital upon Availment in the absence of your HMO card.

Ans: Submit an accomplished ID Replacement Form and pay P250.00 for card replacement fee.

Ans: To avail of services, please present your 1COOPHealth HMO card or virtual card and a valid government-issued ID. A Letter of Authorization (LOA) is also required for availment, subject to the applicable process.

PROVIDER

Ans: Availment must be done at 1COOPHealth-accredited facilities, except in emergency cases.

(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)

Ans: We can invite your doctor for accreditation; however, acceptance of accreditation will depend on the doctor.

Ans: You may share the doctor’s contact information with us so our team can reach out and discuss the accreditation process and requirements.

A. Outpatient (OPD)

Ans: Outpatient services may include doctor consultations, laboratory tests, X-rays and other diagnostics, and minor outpatient procedures. Coverage is subject to your plan’s benefits and limits.

Ans: LOA requests may be processed through the accredited clinic or hospital’s HMO desk or through 1COOPHealth-approved channels such as hotline numbers, mobile numbers, Messenger, or Viber. For Viber 09176296766, Email medical@chmf.coop

Ans: Appointments are recommended, especially for specialist consultations, to avoid delays.

Ans: You may consult a non-accredited doctor and file for reimbursement of the paid professional fee; however, only the HMO rate may be reimbursed.

Ans: Yes. Requested laboratory tests or procedures may be availed outright with a supporting diagnosis.

Ans: Yes. Outpatient services are subject to your Maximum Benefit Limit (MBL) and benefit schedule.

Ans: We are diagnosis-based in covering your availments. Just like other HMOs, 1COOPHealth has certain exclusions.

Ans: Any and all illnesses proven to be related to or is a complication of a certain illness shall share the same Maximum Benefit

Ans: 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 Professional Fees of 30%.

Ans: For inquiries on benefit coverage, you may call any of our Customer Care Hotlines or our Trunkline No. (02) 8-638-8628. Your medical details and needed procedure will be assessed if coverable (or otherwise) by your health plan.

Ans: All the availments of our members are diagnosis- based and thoroughly evaluated by our medical team prior to giving approval. We follow 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.

Ans: 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.

Ans: 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.

Ans: Based on the Benefits coverage of the member. As an HMO, we follow what we term as Clinic Practice Guidelines (CPGs). CPGs serve as a guide to help decide which tests are necessary or not in the diagnosis of the patient or which should come first before proceeding to other related tests. Note: All Pre-existing conditions/illnesses are covered after 1 year or upon renewal of plan and/or as stipulated in your contract.

B. Inpatient (Hospitalization)

Ans: Inpatient services include hospital confinement, room and board based on the member’s plan, accredited doctors’ professional fees, surgery, and in-hospital procedures.

Ans: Go to a 1COOPHealth-accredited hospital, present your HMO card and valid ID, and coordinate with the hospital’s HMO/Admitting section. The hospital will coordinate with 1COOPHealth upon admission and during discharge. Your LOA will be sent to the hospital once the member’s detailed statement of account is received.

Ans: Coverage depends on your plan but may include room and board based on the member’s plan, professional fees of accredited physicians, and diagnostic and laboratory services.

Ans: Any amount beyond your approved benefit limits will be paid out-of-pocket by the member.

Ans: 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 Professional Fees of 30%.

Ans: Patients don’t need to give any payment before admission as long as there is still remaining benefit limit on his account.

Ans:

In this case, you may choose one of the following options:

a. Occupy a lower room category and no incremental cost will be charged.

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 within 24 hrs; 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.

C. Emergency

Ans: A medical condition that requires immediate treatment to prevent serious harm, disability, or death (e.g., accidents, severe chest pain, or loss of consciousness).

Ans: Yes. In emergencies, you may go to the nearest hospital, whether accredited or not. You may file reimbursement for emergency availment at a non-accredited provider.

Ans: The hospital has an LOA process at the emergency department. The member must be attended to first before the hospital coordinates with 1COOPHealth for approval of availment.

Ans: Once stable, transfer to a 1COOPHealth-accredited hospital may be required, or the case may be processed under reimbursement, depending on the circumstances.

Ans: All hospitals have an HMO Department. However, we also have coordinators in some hospitals where members may get their LOAs.

D. Annual Physical Examination (APE)

Ans: All 1COOPHealth enrollees are entitled to an APE after full payment of annual fee. A request for an APE schedule is 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 annualpe@chmf.coop

Ans: Consultations with a medical specialist may be reimbursed based on the HMO rate. As a standard practice, outpatient laboratory tests and procedures are not reimbursable because these should be covered outright. For reconsideration, an explanation letter is required for outpatient availment at an accredited provider and will be evaluated by the Claims team.

Ans: Reimbursement may apply if services were paid out-of-pocket during an emergency at a non-accredited provider, or if a 1COOPHealth-accredited hospital or clinic is far from the member’s point of origin.

Ans: Typical requirements include a duly accomplished reimbursement claim form, original official receipts, an itemized billing statement, and a medical abstract or doctor’s report.

Ans: Processing usually takes within 30 days, subject to document completeness and evaluation.

Ans: Reimbursement is subject to 1COOPHealth-approved rates, your plan’s benefit limits, medical review, and eligibility.

Ans: Reimbursement may be released via check or bank transfer.

Ans: Typical reimbursement requirements include a duly accomplished reimbursement claim form, original official receipts, an itemized billing statement, and a medical abstract or doctor’s report. Additional documents may be requested during evaluation.

Ans: 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.

Ans: Yes. If you do not provide your bank details on the claim form, your reimbursement will be sent to your cooperative, where you can claim it. For faster processing and direct reimbursement, we recommend including your bank details in your claim form.

Ans:

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 subject to the reimbursement provisions.

  1. Reimbursement up to 80% of hospital bills and 100% Reimbursable up to limit based on RUV HMO rate for all availments done in non-accredited providers for areas WITH NO ACCREDITED PROVIDERS.
  2. 100% Reimbursable up to limit based on RUV HMO rate for emergency cases (Subject for evaluation).

c. NO Reimbursement will be made for availment done in an accredited provider except for emergency cases (subject for evaluation).

Ans: If you fail to submit your PhilHealth Benefit Claim Form upon discharge, 1COOPHealth will cover the PhilHealth portion of the hospital bill. However, any amount exceeding your health card benefit limit will be shouldered by the health card holder.

   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.