1. How do I know which doctors are affiliated and with AVEGA?

You may check the list of AVEGA affiliated doctors and their schedule with the AVEGA Hospital Coordinator. You may also call our Customer Service Specialists through telephone numbers 789-4030 or 902-3430 for the list of accredited facilities and additional inquiries or visit our website: www.AVEGA.com.ph.

2. Can I get a copy of the AVEGA list of affiliated doctors?

AVEGA continually updates its list of affiliated doctors, thus it is advisable for you to check and verify their schedules with the AVEGA Hospital Coordinator or call AVEGA’s Trunkline for details.

3. Are AVEGA Hospital Coordinators/Assistant Coordinators available 24 hours a day? What should I do if they are unavailable?

AVEGA has two to three (2-3) Hospital Coordinators per hospital and will accommodate members for outpatient and non-emergency consultations during their specified clinic hours. For other hospitals that have no Coordinators but have an HMO or Industrial office, you may secure AVEGA Referral Forms from the said office.

For medical emergencies, you may proceed directly to the emergency room of the hospital for immediate treatment. However, assessment of whether the case is emergency or not will depend on the Emergency Room physician.

4. If I am in an accredited hospital and want to use the services of my personal doctor who is not accredited, can I have the medical services reimbursed?

Consultation, treatment and referral for diagnostic procedures and/or confinement coming from a non-accredited doctor is non-reimbursable. For you to enjoy the benefits of your health plan, you must avail of your benefits in an AVEGA accredited hospital or clinic and have your case managed by an AVEGA affiliated doctor , except during emergency cases.

5. Can I have my personal doctor/dentist accredited by AVEGA?

You may write a request for accreditation to AVEGA’s Account Management Department or coordinate with your HR Representative to facilitate your request.

The doctor/dentist will be asked to submit necessary requirements to AVEGA and will be evaluated by the company’s Provider Relations Department if qualified to be part of Intellicare’s network.

The doctor may be affiliated only if he/she passes AVEGA’s evaluation and he/she agrees to the payment terms and conditions of our contract. We will give you status update through our Account Officer if your request has been approved or not.

6. During confinement, if I want to occupy a room category higher than what is stated in my plan, may I do so?

Yes, you may occupy a room category higher than what is entitled to you. However, during voluntary upgrading (when you choose to occupy a higher room category even if your allowed room is available), you will pay all incremental charges. Due to socialized pricing in hospitals, the higher the room occupied - the higher the cost of services. This includes room rate, professional fees, medicines, medical supplies, hospital procedures and the like. The same charges may also apply if you are admitted in a hospital that does not provide or does not allow confinement of non-private patients in the room category corresponding to your plan. The AVEGA Patient Relations Officer shall explain and remind you to pay these charges prior to hospital discharge.

7. What if, during the time of my admission, all the rooms under my room category are occupied – what will I do?

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

Occupy a lower room category and pay no incremental charges.

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 day one (1) of confinement.

You may transfer to another accredited hospital if it is a non-emergency case.

Note: Provision on involuntary upgrading of room category may vary according to the plan of the member.

8. What if my illness/condition developed certain complications – will these illnesses have a separate Maximum Benefit Limit?

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

9. Who is responsible for the filing of my Philhealth forms with the hospital? What happens if I fail to file?

It is the member’s responsibility to file the Philhealth forms. If you fail to file upon hospital discharge, you will pay the amount corresponding to your Philhealth benefit and apply for reimbursement directly from the Philhealth Office afterwards.

You may coordinate with your company’s HR Representative during your confinement period to secure a signed Philhealth Claim Form 1, Philhealth contributions and Member’s Data Record (MDR) as well as a Philhealth Claim Form 2 to be signed by your attending physician prior to hospital discharge. AVEGA Patient Relation Officers (PROs) will provide assistance in reminding you to submit the said forms. They, however, will not be directly responsible for the actual filing.

Note: In the case of a non-Philhealth member, member must pay the Philhealth portion of the hospital bill prior to hospital discharge.

10. Do I get 100% reimbursement for my emergency confinement in a non-accredited hospital?

If you were treated in a non-accredited hospital for a medical emergency, AVEGA will reimburse your medical expenses based on the Relative Value Scale (RVS) or rates AVEGA has agreed upon with its accredited providers. The amount will not be exactly the same as the amount that you spent in the non-accredited facility. The same computation applies to emergency confinement cases in non-service areas or foreign countries (please refer to your Emergency Care benefits for the percentage and maximum amount of reimbursement).

11. What is the turn-around time for the submission and processing of reimbursement?

Submission of the duly accomplished AVEGA Reimbursement form and required attachments is within 30 days from the date of hospital discharge or treatment.

AVEGA will process the request within 30 days upon receipt of the complete documents.

12. What should I do if I am asked to pay for medical services which I know are covered?

You should call AVEGA’s Trunkline through telephone numbers 902-3430/789-4030 for assistance and verification of the service being charged.

13. What if the hospital has a cash basis policy for some of the procedures even if they are recommended or performed by an AVEGA-affiliated physician?

You may pay for the cost of the procedure first then file for reimbursement later on. Reimbursement shall be based on the Relative Value Scale (RVS) or pre-agreed rates for laboratory and diagnostic examinations (i.e. CT scan, MRI, etc.). If you do not want to shell out the amount being asked for, you may transfer to another AVEGA-accredited facility that has no “cash basis only” policy. You may call AVEGA’s Trunkline for assistance.

14. Why do I need to pay for the professional fees of accredited Neurologists?

The professional fees of Neurologists at the moment are on a “cash basis” policy for all HMO members. This policy is in accordance with the guidelines set by the Society of Neurologist of the Philippines. You may pay for the cost of professional fees first then file for reimbursement based on AVEGA’s Relative Value Scale (RVS). For any recommended procedures, AVEGA will cover the member immediately according to the plan benefit.

15. What if there is no AVEGA doctor available in any accredited hospital for the field of specialization I need or I am referred to?

AVEGA will exert all its effort to negotiate for the AVEGA rate to be charged once the member is referred to a non-affiliated specialist. If the physician does not agree to the rate, you will be asked to pay the cost of their professional fee first then file for reimbursement based on the AVEGA Relative Value Scale (RVS).

16. What if I get into a vehicular accident – will AVEGA cover the cost of my medical expenses?

In this case, you need to submit a police report and other pertinent documents for any injuries sustained in vehicular accidents and other medico-legal cases (i.e. shooting, stabbing, mauling, etc.) subject for evaluation. AVEGA will not cover injuries resulting from causes under the general exclusions and limitations.

17. If I resign from my company, can I still use my AVEGA Card?

The member’s healthcare benefit is co-terminus with his/her stay with the company. You should surrender your card prior to resignation as this is a requirement of the clearance process. Use of the card after separation from the company is an illegal transaction and the member will be billed for any medical availment incurred after resignation/separation from the company.

18. If I lose my card, what should I do?

You should notify your HR Representative or AVEGA’s Trunkline within 24 hours upon discovery of the loss. You need to submit an Affidavit of Loss and will be charged Php 100.00 for the replacement of the card. If you need medical care while your new card is still being processed, you may contact AVEGA’s Trunkline for endorsement to the medical facility where the procedure or consultation/treatment will be conducted.

19. What should I do if I want to give feedback or report any concerns?

You may e-mail AVEGA at info@AVEGA.com.ph or make an incident report and submit it to your HR Representative. For urgent matters, you may call AVEGA’s Trunkline for immediate assistance. Please give all pertinent information for AVEGA to be able to address the concern/s as quickly as possible.

14/F Phil. AXA Building, Sen. Gil Puyat Avenue cor. Tindalo Street, Brgy. San Antonio, Makati City
902-3430 / 789-4030
info@AVEGA.com.ph
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