In general, to file a claim in ACE Jaya Proteksi is simple. Customers only need to fill the claim’s report and complete the documents required. Then, ACE Jaya Proteksi team will analyze the claim documents based on the Policy. The important thing the customers need to understand is that the damage or loss is covered in the Policy.

HEALTH CLAIM SUBMISSION REQUIREMENT & PROCEDURE

I.           CLAIM REPORT

As one form of our efforts to provide optimum services, we provide call center services which can be access by the participants. Call Center Services Hotline 24 hours ACE Jaya Proteksi can be accessed through

• ACE Jaya Proteksi Hotline number, Telephone No. 500 257 from any landline and mobile CDMA or prefixed with a local area code if calling from a GSM phone.
• Health Insurance Division at telephone number 021-6230 9433 (Monday-Friday at 08.30-17.30 WIB)
• AdMedika at telephone number 021-500811 (24 hours)
• Cynergy Care at phone number 021-29552789 or toll free number 0-800-1333111

Or please send an email to below address:

• Health.ID@acegroupx.com

II.  DEFINITION

Hospital

An institution which is a legal entity and registered as a Hospital in the country where the hospital is based to provide care and treatment for sickness and injury, and the Hospital:

•     Has the facility to perform the diagnosis, treatment and major surgery, and provides care 24 hours a day by nurses who have a license, and

•     Being under constant supervision or headed by a physician and

•     Not a place for recovery, or a vacation home, nursing homes, rehabilitation centers for people who are addicted to alcohol or drugs, hydro-clinic or the like.

ICU Room
A section of the hospital that is permanently set as the Intensive Care Unit of the Hospital, which is open 24 hours solely to provide emergency care / critical that require audio and visual observation continuously, and are equipped to provide care and specialized medical services that are not available elsewhere in that hospital.

General Practitioners
A doctor who qualified and has diploma  in western medical science and has a valid license to practice as a general practitioner that issued by the competent authority of the country in which he practices, and providing care and medical services within the scope of license and expertise.

Specialist
A doctor who has special expertise in western medical science and recognized by the competent authority in the country in which they practices.

Emergency
Health conditions that require immediate healing treatments, in order to avoid death or serious deterioration in the outlook for health, either during the event or for the long term.

Accident

Unexpected events, unplanned, sudden, unforeseen, comes from outside and caused by violence causes bodily injury by accident that regardless of any other cause. Inhalation of gases and vapors and omissions inadvertently consume toxic materials or chemicals are also considered as an accident, with the proviso that only accidental bodily injury that occurs within 30 days from breathed or consumption, it will be considered as the cause of the accident. Drowning is also considered as an accident.

Illness
The physical condition of the deviation from normal and healthy condition.

Excess Costs/Expenses
Costs/Expenses that have been known since the beginning as the obligation of participants, this cost/expenses must be paid by the participant directly to the Hospital / Clinic, such as non- medical expenses (soap, tissue, laundry, sanitary napkins, Pampers and the like).

Excess claim
Medical expenses which are not covered under the insurance policy and become liability of the participant. The excess is known after ACE Jaya Proteksi received a bill from the hospital / clinic and after going through the process of analyzing the claim is known that medical expenses not covered by ACE Jaya Proteksi.

Provider
Network Hospitals / Clinics as a partner of ACE Jaya Proteksi,  to provide medical services to the Participant of ACE Jaya Proteksi’s Health Insurance.

TPA
Third Party Administration, which is a company that has been appointed by ACE Jaya Proteksi to do management of the claim including guarantee of treatment and customer service.

III. Service System

        Provider System

It is a method of service on a "cashless" basis where by carrying ACE Jaya Proteksi Health Insurance card, participants can seek treatment to network clinic / hospital provider (partner) who has worked with ACE Jaya Proteksi health insurance without have to make a payment in cash (except for any costs which are not covered by Health Insurance Policy).

 

All medical bills will be charged by the clinic / hospital provider to ACE Jaya Proteksi for further analysis. In case the costs are not covered by the policy, it will be charged as an excess claims to policyholders and to be paid within 14 days to ACE Jaya Proteksi.

 

2.    Reimbursement System

It is a method of service where participants pay in advance the cost of treatment at the hospital of participant choice, then submit all original invoice including complete claim documents to PT. ACE Jaya Proteksi through Company HR. All documents will be analyzed according to benefits/ coverage contained in the Health Insurance Policy. Claims payment for the approved claim will be made through the company’s bank accounts (or according to the initial agreement between ACE Jaya Proteksi with the company).

Prosedur of Services

PROVIDER SYSTEM

 

• Inpatient, Surgery and Maternity

 

 

*) If EDC machine terminal is not available in the Hospital, the method of service is a show card (The Participants showing ACE Jaya Proteksi Health Insurance card), not necessary to be swiped. The Hospital will contact ACE Jaya Proteksi to get guarantee letter.

 

PROVIDER SYSTEM (Continue..)

•  Outpatient & Dental Treatment

 *) If in the hospital provider EDC machine terminal TPA not available, the method of services is on reimbursement basis

 

 

 

PROVIDER SYSTEM (Continue)

• Glasses

 

Special note coverage Glasses:

1. ACE Jaya Proteksi only covers the purchase of glasses with the size of eye refraction that recommended by ophthalmologist.

2. Purchasing prescription glasses with Optician should be issued prior approval if the participants had to use glasses. This condition does not apply to participants with membership status, child.

3. Purchasing glasses for children should attach a letter of reference / recommendation ophthalmologist.

4. ACE Jaya Proteksi covers the purchase of glasses that have a size of at least 0.5 diopters for minus/plus / cylindris.

5. ACE Jaya Proteksi only guarantees the purchase of glasses in case of changes in the size of refraction of the eye or other conditions according to a description in the policy.

Note : This special note applied only if the participant have glasses benefit as stated in the Policy.

 

Services Procedure

 

 

2.       REIMBURSMENT SYSTEM

To obtain settlement of claim reimbursment, participants must submit a claim to PT. ACE  Jaya Proteksi through his company HR, to include all of the requirements necessary claim documents.

All claim documents will be analyzed according to benefits / coverages contained in the Health Insurance Policy. PT. ACE Jaya Proteksi will settle the claim within 10 working days after the complete claim documents received by the ACE Jaya Proteksi Insurance

*) Expired date of claim submission:

• 30 days after the medical treatment received by participants, for JABODETABEK
• 60 days after the medical treatment, for outside JABODETABEK

 

IV. COMPLETENESS OF CLAIM DOCUMENTS

 

INPATIENT AND SURGERY

• ACE Jaya Proteksi medical claim form completed and signed by the insured and their treating doctor. If claim form not available, can use form that available at the Hospital/Clinic.
• Copy of Ace Jaya Proteksi health membership card.
• The original receipts including the breakdown of medical cost during treatment at the hospital
• The original breakdown of using medicine during treatment including the cost
• The original breakdown medical supporting test including the cost.
• Supporting examination result ( Laboratory, diagnostic test, rontgen, etc)
• A medical certificate from the doctor-in relation to participants hospitalization including the date of commencement of events that resulted in hospitalization, accompanied by the doctor’s signature and seal of the Hospital.
• In the case of documents or evidence supporting the claim submission is incomplete, the Health Insurance  ACE Jaya Proteksi will return all documents to the Participant to be completed through Company HR.
• No later than 30 days after returning of incomplete documents through HR, claim documents including complete supporting document must be re submitted ACE Jaya Proteksi to be reanalyzed.
• ACE Jaya Proteksi entitled to request other evidence relating to medical services

 

MATERNITY

• ACE Jaya Proteksi maternity claim form must be completed and signed by participant and the treating doctor/physician/specialist/midwife.
• Copy of ACE Jaya Proteksi Health Insurance Card
• All bills and the complete original receipt from the Hospital related to hospitalization in the hospital, and
• All bills and the complete original receipt from Doctor / Specialist / Midwife
• Letter from doctor or midwife regarding the condition and the expected date of commencement of pregnancy.

 

OUTPATIENT AND DENTAL TREATMENT

• ACE Jaya Proteksi Health Insurance Claim Form for Outpatient/dental treatment must be completed, signed by Participant and the doctor/ Specialist / Dentist who treated/cared.
• Copy of ACE Jaya Proteksi Health Insurance Card.
• Bills and the original complete receipt from Doctor / Specialist / Dentist
• Copy all the prescription, all of the original bills, and all the original receipt when purchased drugs at pharmacies
• Laboratory Examination Result, along with the letter of recommendation to conduct laboratory tests from Doctor / Specialist / Dentist along with all original bills and receipts

 

Note: *) If the Claim Form of Dental Care/ Outpatient treatment not be carried away by the participants at the time of treatment, on the original receipt must be included medical diagnosis given by a physician who treats with signature and seal of the treating doctor.

 

GLASSES

• Proof of payment of the purchase of lenses and / or frames from official optical, in which the receipts must be in the form of computerized
• The results of the examination of the eye acuity from Ophthalmologist or Refraksionis.

 

Important !

 

SPECIAL NOTE CARD PARTICIPANTS

Do not carry a Participant’s card

 

For the case of hospitalization, participants forget or do not carry ACE Jaya Proteksi health insurance cards, please contact Customer Service ACE Jaya Proteksi Health Insurance to request initial guarantee letter. Initial guarantee valid for 2 x 24 hours. Participants are expected to be able to show the card Participant after the deadline. If the card is not available, there should be an explanation of the HR company in writing that describe the status of the Card Member.

For outpatient cases, when participants forget or do not carry ACE Jaya Proteksi health insurance cards, the participant is considered as a public patient. Participants must pay in advance the cost of treatment and subsequently filed a reimbursement claim to ACE Jaya Proteksi through HR company.

 

Membership card lost or damage

• Please contact Customer Service Asuransi ACE Jaya Proteksi at phone number 500 257 from dari home phone dan CDMA or starting with the local area code if calling from a mobile phone GSM (07.00 am - 24.00 pm)
• Reporting to the HR Policy Holder / Company
• Submission of a new card is lost or damaged should be proposed by the HRD Policyholder / Corporate and administrative charge of printing new cards is Rp 25,000.

 

SPECIAL NOTES FOR INPATIENT BENEFIT

Warranty provisions for Inpatient

Inpatient Guarantee applies if the Participant admitted to the hospitalization within at least eight (8) hours for necessary health care due to illness or accident referred doctor. Especially for surgery, this provision does not apply.

 

Hospitalization abroad

If participants choose to hospitalization abroad, the system applies reimbursment. Participants must pay the cost of treatment in advance then submit it to PT. ACE Jaya Proteksi, as reimbursment claims procedure (on page 9).

 

Entitled Room & Board are not available due to full book

• Participants will be placed in room higher one level for 2x24 hour as long as not exceed maximum limit benefit of the Participant as stated in the policy. After a period of 2x24 hours, and the entitled room still not available, then:

a. Participants will be moved back to room treatments one (1) levels lower until the room & board as per participant entitlement is  available, or

b. Participants can still occupy the room with the provision that the participants have to bear the difference in the treatment room since the 3^rd day.

• If within 2x24 hours Participants entitled room already available, the participants had to move rooms according to their rights. If a participant is not willing to occupy the rooms according to their entitled room, then the participants have to bear the difference in cost of the increase in class since the first day of treatment rooms in accordance with APS (On Self Demand)

 

Room rate as per Participant entitlement is not available at the Hospital

• Participants must occupy a lower room and board rate

• If the lower rate is not available, then the ACE Jaya Proteksi  will give tolerance room & board rates by 20% of the room rate at the participants entitled or Rp. 50,000 (whichever is lower)

• If the room rate does not exceed the tolerance given rate, the difference rate between entitled room with the occupy room cost will be borne by the participants.

• If the rate exceeds the tolerance tariff treatment provided, the benefits are not applicable tariff tolerance by itself and apply the same provisions as the provisions of the conditions of APS (On Self Demand)

 

Conditions APS (On Demand Self)

That is a condition where since the beginning the room occupied by participant is higher than his entitled room on his own request or Participants treated abroad. In this case, the participant must pay in advance the cost of treatment is going on and then propose reimbursement to ACE Jaya Proteksi Insurance,  as per reimbursement claims procedure (on page 9). The maximum reimbursement is as per conditions listed in the policy.

 

SPECIAL NOTE FOR OUTPATIENT BENEFITS

Participants were asked to pay in cash for the purchase of vitamins / multivitamins

When in network hospital / clinic provider,  Participants were asked to pay in cash the cost of purchasing vitamins / multivitamins, participants can still make a claim purchase vitamins / multivitamins on reimbursement basis according to the conditions of the policy.

 

Terms repetition purchase prescription drugs (iter)

Purchasing prescription drugs repetition (iter) a maximum of two (2) times were made ​​within 14 (fourteen) days from the first recipe submitted. Except already get written approval of the medical team ACE Jaya Proteksi

 

Excess Cost and Excess Claims

 

Excess Cost

Excess costs are those costs which from the beginning has been known to be a participant liability, costs shall be paid by the participant directly to the Hospitals / Clinics.

 

Completion Excess Cost

If there is excess cost, the Participant is required to pay the entire cost of the excess before leaving the hospital.

Examples of services that result in excess Cost:

• Costs not covered by the policy and / or not medically necessary, such as diapers, phone use, perlak, minibar, sanitary napkins, and others.

 

 

Excess Claim

Excess claims are costs that are not covered and being obligation of the Participant. The excess is known after ACE Jaya Proteksi receive bill from the hospital / clinic and after going through the process of analyzing the claim is known that there are costs that are not covered by ACE Jaya Proteksi.

 

Completion Claims Settlement

• Ace Jaya Proteksi will send excess claim letter to the participant through HR Company.

• Participants must make payment within 14 (fourteen) days since the date of excess claim letter issued.

• Failure to fulfill payment within 14 (fourteen) days, participant’s card will temporary unusable until the excess claim settlement done.

                                                    

Examples of Excess Claim:

• Treatment is fall under policy exclusion.

 

Settlement of Bill

• Participants pay excess claims bill to the Policy Holder / Company. Then the ACE Jaya Proteksi accept bill payments excess of policyholder claims / Vendor

• With the permission of Policy holder/ Company, Participants can pay the excess claim directly to ACE Jaya Proteksi.

PROCEDURE FOR EXCESS CLAIMS SETTLEMENT BY PARTICIPANT TO ACE JAYA PROTEKSI DIRECTLY:

1. By bank account transfer, addressed to the following bank account

 

2. By a cash deposit, the Parties shall mencantumkam news on deposit payment sheet, which contains:

• Company Name

• Employee Name

• No. Claims (available on excess bill from ACE Jaya Proteksi)

In this case, participants are required to pay the administrative costs imposed the sender Bank.

 

3. By the transfer via ATM, the ATM machine that has the facility to include the sender's message (Non-Cash ATM), the Participant is required to include the sender's message, which contains:

• No. Claims (available on excess bill from ACE Jaya Proteksi)

In this case, participants are required to pay the administrative costs imposed the sender Bank.

 

4. If participants make payments through one of the above media without sending news, then after making the payment, participants MUST notify ACE Jaya Proteksi, via email: Health.ID @ acegroup.com by stating:

• Company Name

• Employee Name

• No. claims

• Nominal payments

 

5. Payment of the excess claims in the absence of news or clear information, can not be recorded as a settlement

 Form Hospitalization and Surgery actual size 2 plies

 

 Form Maternity Claim, actual size, 2 plies

Form Dental Claim, actual size, 2 plies