Health Claim Guide of AXA Smartcare Exclusive

Transcription

1 Health Claim Guide of AXA Smartcare Exclusive

2 Table of Contents FOREWORD..3 CONTACT US 3 1 PRE-AUTHORIZATION Pre-authorization Requirements Pre-authorization Procedures..5 2 AXA ELECTRONIC MEDICAL CARD INTRODUCTION OF DIRECT BILLING SERVICES (OUTPATIENT AND INPATIENT) MAINLAND CHINA Outpatient Direct Billing Service Procedures Through POS Machine (Mainland China) Outpatient Direct Billing Service Procedures Offline Transaction (Mainland China) Inpatient Direct Billing Service Procedures (Mainland China) 8 4 INTRODUCTION OF DIRECT BILLING SERVICES (OUTPATIENT AND INPATIENT) HONG KONG Outpatient Direct Billing Service Procedures Through Backend System (Hong Kong UMP Clinics) Hong Kong QHMS Clinics Out-patient Direct Billing Service Procedures Hong Kong QHMS Clinics In-patient Direct Billing Service Procedures.11 5 INTRODUCTION OF DIRECT BILLING SERVICES (OUTPATIENT AND INPATIENT) THAILAND, MALAYSIA, VIETNAM, SINGAPORE Out-patient Direct Billing Service Procedures (Thailand, Malaysia, Vietnam, Singapore) In-patient Direct Billing Service Procedures (Thailand, Malaysia, Vietnam, Singapore) INTRODUCTION OF DIRECT BILLING SERVICES THE UNITED STATES OF AMERICA 6.1 Direct Billing Service Procedures (The United States of America).14 7 PROCEDURES AT NON-PANEL HEALTHCARE PROVIDERS 15 8 MEDICAL SECOND OPINION SERVICE (MSO) The Importance of MSO Procedures to Apply for MSO 16 APPENDICES Appendix 1 Direct Billing Medical Providers (Mainland China) Appendix 2 Direct Billing Medical Providers (Hong Kong) Appendix 3 Direct Billing Medical Providers (South East Asia) Appendix 4 Medilink Member Portal user guide Appendix 5 Pre-authorization Request Form Appendix 6 Claim Form for direct billing provider's outpatient Appendix 7 List of High Cost Providers Appendix 8 Qualifying Medical Conditions for MSO Service Appendix 9 Frequently Used MSO Service Contracted Medical Organizations Appendix 10 Health loss notice for Non-panel healthcare providers Page 2 of 18

3 FOREWORD Welcome to your Health Claim Guide of AXA SmartCare Exclusive! This Health Claim Guide provides guidance on the following areas: How to select a panel hospital with Direct Billing settlement services How to make a claim How to seek for Medical Second Opinion Service, and Other services provided according to your policy CONTACT US While it is important that you read and understand your Health Claim Guide, we understand that it is often easier to call us to obtain information. If you have any inquiry with regards to the terms and conditions of your policy, please call us at (+86) (Monday to Friday 9:00am-5:30pm). INSTRUCTION MANUAL This Health Claim Guide have listed all the hospitals worldwide and in China mainland covered by your policy with which we have what is known as a Direct Billing settlement agreement. This means that when you seek out-patient/in-patient treatment at any of the listed panel hospitals, we will enable you to enjoy cashless admission to the hospital, provided that you have passed pre-authorization for your treatment in advance (following our procedures outlined in this Health Claim Guide). During discharge from the hospital, you will also enjoy cashless payment service up to a certain pre-approved amount; however the final medical bill is subject to final claim review and approval. Basically, with Direct Billing, most of the time you won t have to pay in advance for your care and then claiming the reimbursement from us. You should return the payment which are due to network settings errors, additional payment or excess payment caused by other errors. Insurance company only provide Direct Billing settlement for the treatment falling under the scope of the policy and in the event that charges incurred are not claimable from the policy for any reason, you shall undertake to pay back to the insurance company. ATTENTION Before you go for medical treatment, it is important to check the hospital network in each geographical area to ensure the treatment facility you are intending to use Page 3 of 18

4 is covered under Direct Billing. In addition, the manual also states the claim procedure when you go to a non-panel hospital We have contracted with Medilink, an international medical Third Party Administrator (TPA), and its affiliated organizations to offer healthcare provider access and Direct Billing settlement with a network of hospitals in certain areas subject to the insurance plan you have selected, including Mainland China, Hong Kong, Thailand, Malaysia, Vietnam, Singapore and USA. Before your treatment, you need to make sure your insurance covers the area above the medical care or medical institutions. In other words, only if your insurance covers the area above medical insurance or medical institutions, you can enjoy direct-billing services. Please note that if your single outpatient expense in total exceeds Chinese RMB 5,000 or equal amount of other currency, you will be not eligible for Direct Billing settlement but need to follow the procedure as at non-panel healthcare providers. CONTACT THIRD PARTY MEDILINK OR MEDICAL PROVIDERS If you need assistance in obtaining pre-authorization, confirm your coverage, locating Direct Billing medical providers in Mainland China, Hong Kong, Thailand, Malaysia, Vietnam, Singapore and USA (please refer to parts 3-6 of this Health Claim Guide), or seeking for Medical Second Opinion service (please refer to part 8 of this Health Claim Guide), please call our contract Medilink at its 24/7 toll free hotline at (+86) If you are travelling in Malaysia, Vietnam, Thailand, Singapore, you could also dial (006) for an easy and quick Direct Billing arrangement to the medical providers best suitable for you. Likewise, if you are travelling in USA, you could dial (001) to quickly locate the medical providers within our Direct Billing network. If you are seeking medical treatment outside of the areas with our Direct Billing medical providers network, you will need to pay for your treatment when you attend, and then send us the receipts to claim a refund from us (please refer to part 7 of this Health Claim Guide). For Emergency Medical Attention, Emergency Medical Evacuation and Repatriation, please call AXA-Assistance at (852) Page 4 of 18

5 1. PRE-AUTHORIZATION Important: Pre-authorization is required before certain medical procedures or treatments are undertaken. Either direct-billing medical providers or use of non-panel hospitals, pre-authorization is required, otherwise you may fail to enjoy our services and medical benefits, or you may spend additional non-reasonable or unnecessary expenses without insurance compensation. The following Medical Services require Pre-authorization, all Inpatient admissions and/or treatments any surgery requiring general anesthesia (outpatient or inpatient) dental treatment home nursing care organ transplants and other similar procedures outpatient kidney dialysis cancer treatment 1.1 Pre-authorization Requirements Pre-authorization is a process by which an insured member obtains written approval for certain medical procedures or treatments, from us or from our contracted TPA on our behalf, prior to the commencement of the proposed medical treatments. The insured member should submit a completed Pre-authorization Request Form to us or our contracted TPA. This completed form should be received by us or our contracted TPA a minimum of 5 working days prior to the scheduled procedure or treatment date. We will review the case and respond to the insured member. The written approval should be received by the insured member, prior to the commencement of the proposed medical treatment. In addition, during retroactive claim review, if the care is determined to be a procedure that would have been approved by us, failure to comply with the Pre-authorization procedures also disqualify the member for the reimbursement for any out-of-pocket expenses. On the other hand, upon retroactive review of medical records, if the care is determined to be a medical procedure that would not have been approved, the entire claim will be denied. Considering the fact that is impossible to forecast a medical emergency, the insured person could inform us within 48 hours after the emergency happened. Notice : Notwithstanding the requirement to pre-authorize: Pre-authorization approval does not guarantee payment of a claim in full, as additional deductibles/co-payment and out-of-pocket expenses may apply. Benefits payable under the policy are still subject to eligibility at the time charges are actually incurred, and to all other terms, limitations, and Page 5 of 18

6 exclusions of the policy. If there is any cost not claimable, you should undertake to pay back to us. 1.2 Pre-Authorize Procedures Complete the Pre-authorization Request Form. This form can be found in Appendix 5 or downloaded from the member portal online access on Contact Medilink at (+86) and arrange to send your completed Pre-authorization Request Form to them via fax to (+86) , no later than 5 business days prior to the scheduled treatment date. Written approval must be received prior to the commencement of treatment. It will be 2 working days in approving the authorization form and we will fax back to you or your doctor. If your medical expenses are too high or the length of staying for too long, we may take longer time to review, under normal circumstances would within 5 working days to respond. 2.1 AXA Electronic Medical Card When you opt for SmartCare Exclusive plan, you will get our exclusive AXA medical card. A list of panel hospitals/clinics is provided for you to choose from. No need to make any medical payments (except for the deductibles/co-payment) subject to the terms and conditions of your coverage, when you present your AXA medical card along with your valid ID to the listed hospitals/clinics. The medical card is limited to your personal use, you may not lend, sell, mortgage, Page 6 of 18

7 etc. for non-personal use behavior. If you breach the rules, our company reserves the right to refuse to pay reasonable compensation or appropriate to your false submitted claims. Your insured person will be disqualified if your behavior constitutes the insurance contract to be terminated or invalid. Please take care of the first AXA medical card which will be free issued to you. If you lose it, please promptly contact with us for the replacement at your own cost. 3. INTRODUCTION OF DIRECT BILLING SERVICES (OUTPATIENT AND INPATIENT) - MAINLAND CHINA 3.1 Outpatient Direct Billing Service Procedures Through POS Machine (Mainland China) Step 1 Make Appointment Please contact the direct billing provider to make the appointment. If this is the first time you seek treatment at this provider, you may also contact Medilink at for appointment assistance. Step2- Eligibility Verification When you visit a provider, please present your Insurance Card along with your photo ID (ID cards, passports) at the front desk. Once the front desk staff confirms it is yourself who are seeking the treatment, he/she will swipe the Insurance Card at the POS machine, and print out an Eligibility Verification slip. Step 3 Fill in the Claim Form (Appendix 6) Please fill in and sign the front page of the claim form when you are waiting for the treatment. There will be printed claim form available at the direct billing providers front desk. You may also call for the electronic copy of the claim form or download it from the online member portal at Step 4 - See the Doctor Step 5 Real-time Claim Confirmation The billing staff will input your treatment details to the POS machine in order to facilitate an online real-time validation and claim confirmation. POS machine will print out a claim confirmation slip once the confirmation is done. Please read the slip carefully and sign it once you have confirmed all the contents. Please kindly check the printed slip and pay the self-paid amount to the provider accordingly if any self-paid amount is incurred. Step 6 - Discharge Remarks: 1. The charges shown on the printed slip are preliminary assessment of your benefit coverage. You are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of Page 7 of 18

8 the Policy. 2. Some of the direct billing providers are unable to accept your self-paid amount (if any), due to restraints of their internal accounting system. In this case, Medilink on behalf of us will collect the self-paid amount from you within 30 days after receiving the complete medical information from the providers. Your understanding and cooperation will be highly appreciated. 3.2 Outpatient Direct Billing Service Procedures Offline Transaction (Mainland China) If the POS machine at the provider does not work properly or if there is anything wrong with your insurance card, we provide an optional Offline Transaction claim service for you. The front desk staff at the provider will call up Medilink when you are seeking the treatment to do both eligibility verification and claim confirmation from the back-end system. Step 1 Make Appointment Please contact the direct billing provider to make the appointment. If this is the first time you seek treatment at this provider, you may also call at for appointment assistance. Step2- Eligibility Verification When you visit a provider, please present your Insurance Card along with your photo ID (ID cards, passports) at the front desk. Once the front desk staff confirms it is yourself who are seeking the treatment, he/she will call up Medilink for eligibility verification. Medilink will process the request at the backend system, and fax the confirmation slip to the provider. Step 3 Fill in the Claim Form (Appendix 6) Please fill in and sign the front page of the claim form when you are waiting for the treatment. There will be printed claim form available at the direct billing providers front desk. You may also call for the electronic copy of the claim form or download it from the online member portal at Step 4 - See the Doctor Step 5 Real-time Claim Confirmation The billing staff will call up Medilink again after your treatment. Medilink will process your claim at the backend system and will fax the claim confirmation slip to the provider. Please read the slip carefully and sign it once you have confirmed all the contents. Please kindly check the printed slip and pay the self-paid amount to the provider accordingly if any self-paid amount is incurred. There will be 2 copies of the printed claim confirmation slip. You may keep one copy and leave the other one to the provider. Page 8 of 18

9 Step 6 - Discharge Remarks: 1. The charges shown on the printed slip are preliminary assessment of your benefit coverage. You are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of the Policy. 2. Some of the direct billing providers are unable to accept your self-paid amount (if any), due to restraints of their internal accounting system. In this case, Medilink on behalf of us will collect the self-paid amount from you within 30 days after receiving the complete medical information from the providers. Your understanding and cooperation will be highly appreciated. 3.3 Inpatient Direct Billing Service Procedures (Mainland China) Step 1 Pre-authorization Application If your attending physician at the direct billing provider suggests you for in-patient treatment, he/she needs to fill in the Pre-authorization Form (Appendix 5) and fax to us at (+86) Step 2 - Guarantee Letter Issuing If the proposed treatment and diagnosis is covered under the Policy,we will fax the Guarantee Letter to the provider, with the guaranteed amount also printed on it. Pre-authorization maybe revoked if new information subsequently negates a claim. If the proposed treatment and diagnosis is not covered under the Policy, we will fax a Direct Billing Decline Letter to the provider. In this case, you may still take the in-patient treatment, but you have to pay the full medical expense yourself. Step3 - Eligibility Verification When you are admitted to the hospital, please bring your Insurance Card along with your photo ID (ID cards, passports) to the front desk. Once the front desk staff confirms it is yourself who are seeking the treatment, he/she will swipe your Insurance Card at the POS machine or call up Medilink to get the Eligibility Verification slip. Medilink will fax an updated Guarantee Letter to Provider at the same date. Step 4 - Pre-assessment for the Medical Bill We will perform a Pre-Discharge Billing Assessment for the whole medical bill at the time of your discharge. A Statement of Approved Claims will be generated and faxed to the provider. Please read the Statement of Approved Claims carefully and sign it if you agree with all the content. Please kindly check the printed slip and pay the self-paid amount to the provider accordingly if any self-paid amount is incurred. Step5 - Discharge Page 9 of 18

10 Remarks: 1. The charges shown on the printed slip are preliminary assessment of your benefit coverage. You are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of the Policy. 2. Some of the direct billing providers are unable to accept your self-paid amount (if any), due to restraints of their internal accounting system. In this case, Medilink on behalf of us will collect the self-paid amount from you within 30 days after receiving the complete medical information from the providers. Your understanding and cooperation will be highly appreciated. 4. INTRODUCTION OF DIRECT BILLING SERVICES (OUTPATIENT AND INPATIENT) HONG KONG 4.1 Out-patient Direct Billing Service Procedures Through Backend System (Hong Kong UMP Clinics) Step 1 Make Appointment Please contact the Hong Kong UMP Clinics directly to make the appointment. If this is the first time you seek treatment at this provider, you may also call (+86) for appointment assistance. Step2- Eligibility Verification When you visit a provider, please present your Insurance Card along with your photo ID (ID cards, passports) at the front desk. Once the front desk staff confirms it is yourself who are seeking the treatment, he/she will process the Eligibility Verification, and print out an Eligibility Verification slip. Step 3 Fill in the Claim Form Please fill in and sign the front page of the claim form when you are waiting for the treatment. There will be printed claim forms available at the direct billing providers front desk. You may also call (+86) for the electronic copy of the claim form or download it from the online member portal at Step 4 - See the Doctor Step 5 Real-time Claim Confirmation The billing staff will input your treatment details to the backend system and an online validation real-time claim confirmation will happen. The system will print out a claim confirmation slip once the confirmation is done. Please read the slip carefully and sign it once you have confirmed all the contents. Please kindly check the printed slip and pay the self-paid amount to the provider accordingly if any self-paid amount is incurred. Page 10 of 18

11 Step 6 - Discharge Remarks: 1. You can always seek assistance by calling our 24-Hour Service Hotline at (+86) If your treatment is not payable under the Policy or if the contracted TPA (i.e. Medilink) is temporarily unable to confirm whether your condition is covered based on your Policy, a decline of Direct Billing Notification will be sent to UMP. Nevertheless, you can still take the treatment, but the medical expense may be your responsibility, in which case you are entitled to file a reimbursement claim with all the necessary documents. 3. The charges shown on the printed slip are preliminary assessment of your benefit coverage. You are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of the Policy. 4.2 Hong Kong QHMS Clinics Out-patient Direct Billing Service Procedures Step 1 Make Appointment If you seek treatment at one of the QHMS clinics, you should call our 24-Hour hotline at (+86) for appointment. It would be useful to have the following information when you call: Patient s insurance card number Patient name & date of birth Patient mobile phone number and address Admission date Symptom or diagnosis Step2- Eligibility Verification When you visit a provider, please present your Insurance Card along with your photo ID (ID cards, Passports) at the front desk. Once the front desk staff confirms it is yourself who are seeking the treatment, he/she will assist you in your treatment. Step 3 Fill in the Claim Form Please fill in and sign the front page of the claim form and the self-pay confirmation letter when you are waiting for the treatment. There will be printed claim form and self-pay confirmation letter available at the direct billing providers front desk. You may also call (+86) for the electronic copy of the claim form or download it from the online member portal at Step 4 - See the Doctor Step 5 Discharge Medilink will make a direct billing arrangement with QHMS Clinics for your Page 11 of 18

12 medical expenses, and will perform a Pre-Discharge Billing Assessment for the whole medical bill at the time of your discharge. Please kindly pay the self-paid amount to the provider accordingly if any self-paid amount is incurred. Remarks: 1. You can always seek assistance by calling our 24-Hour Service Hotline at (+86) If your treatment is not payable under the Policy or if the contracted TPA (i.e. Medilink) is temporarily unable to confirm whether your condition is covered based on your Policy, a decline of Direct Billing Notification will be sent to QHMS. Nevertheless you can still take the treatment, but the medical expense may be your responsibility, in which case you are entitled to file a reimbursement claim with all the necessary documents. 3. The charges shown on the Pre-Discharge Billing Assessment are preliminary assessment of your benefit coverage. You are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of the Policy. 4.3 Hong Kong QHMS Clinics In-patient Direct Billing Service Procedures Step 1 Pre-authorization Application If your attending physician at the Hong Kong QHMS clinics suggests you for in-patient treatment, he/she needs to fill in the Pre-authorization Form and fax to (+86) Step 2 - Guarantee Letter Issuing If the proposed treatment and diagnosis is covered under the Policy, we will fax the Guarantee Letter to the provider, with the guaranteed amount also printed on it. If the proposed treatment or diagnosis is not covered under the Policy, we will fax a Direct Billing Decline Letter to the provider. In this case, you may still take the in-patient treatment, however you will have to pay the full medical expense on your own. Step3 - Eligibility Verification When you are admitted to the Hospital, please bring your Insurance Card along with your photo ID (ID cards, passports) at the front desk. Once the front desk staff confirms it is yourself who are seeking the treatment, he/she will assist you in your treatment and call up Medilink to get the Eligibility Verification. We will fax an updated Guarantee Letter to the Provider on the same date. Step 4 - Pre-assessment for the Medical Bill We will perform a Pre-Discharge Billing Assessment for the whole medical bill at the time of your discharge. Please kindly pay the self-paid amount to the provider accordingly if any self-paid amount is incurred. Step5 - Discharge Page 12 of 18

13 Remarks: 1. You can always seek assistance by calling our 24-Hour Service Hotline at (+86) If your treatment is not payable under the Policy or if the contracted TPA (i.e. Medilink) is temporarily unable to confirm whether your condition is covered based on your Policy, a decline of Direct Billing Notification will be sent to QHMS. Nevertheless you can still take the treatment, but the medical expense may be your responsibility, in which case you are entitled to file a reimbursement claim with all the necessary documents. 3. The charges shown on the Pre-Discharge Billing Assessment are preliminary assessment of your benefit coverage. You are obligated to accept the final adjustment in charges and actions if there is any miscalculation or uncovered item according to the terms and conditions of the Policy. 5. INTRODUCTION OF DIRECT BILLING SERVICES (OUTPATIENT AND INPATIENT) THAILAND, MALAYSIA, VIETNAM, SINGAPORE 5.1 Out-Patient Direct Billing Service Procedures (Thailand, Malaysia, Vietnam, Singapore) Step 1 - Eligibility Verification When you visit a clinic, please present your Insurance Card along with your photo ID or passport. The clinic staff shall contact our 24-hour hotline (006) for Eligibility Verification. An Eligibility confirmation with approval code shall be provided to you vide the Clinic, should you be eligible for the said coverage. A Declined Verification shall be provided to you vide the Clinic accordingly, should your eligibility is declined. You are required to settle all medical expenses prior to leaving the clinic, should you choose to continue the treatment. Step 2 Proceed to seek consultation from the Doctor. Upon consultation, the Doctor shall complete a brief Data Capture Form with relevant information and this form shall be sent to Medilink as audit and record purposes. Step 3 - Claim Confirmation The clinic staff will seek final approval from Medilink by contacting our 24 hours call centre. Upon claim adjudication and confirmation, a Final Approval Code shall be provided to the Clinic for this specific visit. You are required to confirm your acceptance and agreement to the Data Capture Form and settle your self-paid amount in full to the Clinic directly prior to leaving the Clinic. Step 4 - Discharge Remarks: Some of the direct billing providers are unable to accept your self-paid or out-of-pocket amount (if any), due to their internal financial policies. In such case, Medilink will collect the self-paid amount or out-of-pocket expenses from you within 30 days after receiving the complete medical information from the providers. There are events that your medical Page 13 of 18

14 condition is not covered under your insurance policy, Medilink has the rights to collect the full non-covered amount from you within 30 days after receiving the complete medical information from the providers, even if a Final Claim Approval was authorized at the Clinic. Your understanding and cooperation will be highly appreciated. 5.2 In-Patient Direct Billing Service Procedures (Thailand, Malaysia, Vietnam, Singapore) Step1- Eligibility Verification and Confirmation When you visit a provider, please present your Insurance Card along with your photo ID or passport. The Hospital s Front Desk Officer will contact our 24-hour hotline (006) for Eligibility Verification. Eligibility confirmations Letter (Letter of Authorization, L.O.A) shall be faxed to you vide the Hospital, which specifies your eligibility entitlement and coverage per your insurance policy. Step 2 - Guarantee Letter Issuing Upon receiving the medical report which is completed by the treating physician, Medilink will assess the medical conditions as against your insurance policy s terms and conditions. An Admissibility Confirmation Letter with specific guarantee limit is forwarded to the Hospital, should the hospitalization is admissible.pre-authorization maybe revoked if new information subsequently negates a claim. If the case is not covered under the policy or the medical condition is inconclusive, a Decline Notification is forwarded to the Hospital instead. You could choose to continue treatment at your own cost. Medilink and your insurance company shall not be liable to any of your medical expenses for this given treatment episode. Step 3 - Pre-Discharge Billing Assessment Medilink s claim specialists will perform a Pre-Discharge Billing Assessment in accordance with your available limit and the necessity of the medical treatment. Upon claim adjudication, a Statement of Approved Claims will be generated which identify the self-pay amount (if any). Please sign on the Statement of Approved Claims to confirm your acceptance and agreement to the Statement of Approved Claims and settle your self-paid or out-of-pocket amount in full to the Hospital directly prior to leaving the Hospital. Step4 - Discharge Remarks: Some of the direct billing providers are unable to accept your self-paid amount (if any), due to their internal financial policies. In such case, Medilink will collect the self-paid amount from you within 30 days after receiving the complete medical information from the providers. Your understanding and cooperation will be highly appreciated. 6. DIRECT BILLING SERVICE PROCEDURES (THE UNITED STATES OF AMERICA) Page 14 of 18

15 Step 1 Make Appointment If this is the first time you seek treatment in US, you may contact HAA s local hotline at (001) for appointment consultation. HAA will arrange the appointment and direct billing for you. You may also contact Medilink at for pre-appointment assistance if the case is not very urgent Please kindly provide the following information when you are calling the hotline: Patient s insurance card number Patient s name & date of birth Patient s mobile phone number and address Provider s name Admission date Symptom or diagnosis Step2- Eligibility Verification When you visit a HAA s direct billing provider, please present your Insurance Card along with your photo ID (ID card, passport) at the front desk. Once the front desk staff confirmed that you are the valid member he/she will notify HAA, and ask for further payment arrangements. Step 3 - See the Doctor Step 4 - Discharge HAA will make a proper arrangements with the provider for your medical expenses.you will get an explanation of benefit (EOB) after insurance company finished the claim processing within 90 business days after you treatment. Please kindly pay the self-pay amount to the Provider if there is any prior to leave the medical provider. Remarks: Please feel free to call HAA at(001) whenever you need help.. If you have to take treatment in a non-panel provider in US, please also try to call HAA at (001) for assistance. HAA will coordinate with the provider for both of the direct billing arrangement and negotiation of the discount for you. If the provider refuses to accept the direct billing, you may have to pay for the related medical expenses first then file the claim to the insurance company for reimbursement. Page 15 of 18

16 If your treatment is not payable under the policy or HAA temporarily unable to confirm whether your condition is covered based on the information provided, a decline of direct billing notification will be send to that provider. In that situation, you can still take the treatment, but you need to pay the medical expense upfront. In the latter situation of issue 3, you are pay the bill first and file the claim to the insurance company. Your understanding and cooperation will be highly appreciated. 7. PROCEDURES AT NON-PANEL HEALTHCARE PROVIDERS If you choose to go to a hospital or clinic that is not listed in the Direct Billing Providers list, we may still be able to settle your bills directly with the healthcare provider, with the understanding that more arrangements and procedures with the healthcare providers might be required. For Inpatient, you should still follow the steps of Pre-authorization and we will then discuss the matter with the hospital concerned. For Outpatient, you will need to pay for your treatment when you attend, and then send Winterthur Insurance (Asia) Ltd. Shanghai Branch the receipts to claim a refund from us. Required procedures to be performed by the insured member: 1. Notice us by calling at (+8621) within 30 days from the date of treatment and submit the original bills and receipts of the claim expenses within 60days from the date of treatment. 2. Make sure that the original bills and receipts show the date of treatment, patient's name, and diagnosis with attending physician's stamp and signature. 3. Submit the doctor's referral in claiming any Specialist, X-Ray or Laboratory expenses. 4. Complete the appropriate claim forms obtainable from AXA General Insurance. (Appendix 10) 5. Other materials necessary. Upon receiving the required claim materials, we will: Page 16 of 18

17 1. Settle the claim in pre-agreed payment method within 10 working days.. 2. In other cases, we will let you know if we need any more information. 8. MEDICAL SECOND OPINION SERVICE (MSO) Once the insured member is suspected to have or diagnosed with the diseases listed in the MSO Diagnosis Items (please refer to Appendix 8), we will choose 3 top Medical Institutions for that disease for him/her to select for medical second opinion service. MSO is mainly for life threatening diseases such as: Cancer, benign tumor, congenital heart disease, etc. (please refer to Appendix 8). The MSO network contains over 100 top Medical Institutions all over the world, and will provide professional MSO service to the members, giving additional protection for your health and life (please refer to Appendix 9) 8.1 The importance of MSO Although MSO will not change the previous diagnosis in most cases, it is a great way to detect any mis -diagnosis. It is very difficult for an individual doctor to be aware of the latest technology and advanced medical knowledge. By leveraging on the pool of knowledge from the top Medical Institutions worldwide, it leaves more chance for the insured member to receive alternative treatment options from the top doctors. If MSO confirms the first diagnosis, the insured member could have a more peaceful mind and have more acceptances to the current treatment plan, which could help to encourage and ensure better treatment result most of the time. 8.2 Procedures to apply for MSO Service Page 17 of 18

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