International Health

PACIFIC CROSS CLAIM

A. MEDICAL CLAIMS

1. Direct Billing Services Claims:

• Please visit our website “Customer Center”– Medical Provider Network to get the list of Direct Billing Facilities which provide Cashless Services to customers of Pacific Cross Insurance;
• Please show a valid Coverage Card issued by Pacific Cross Insurance and photographic ID (or Passport) when visiting a Clinic/Hospital which is in the list of Medical Providers for Direct Billing Services;
• Please complete page one of the Notification of Claim Form; request a chance to check your Invoice to ensure all information is accurate and, if possible, sign the Invoice after receiving all medical services.

2. Pay & Claim:

A claim can be made with the following supporting documentation

• Notification of Claim form: completed by Claimant and Attending Physician;
• Medical Report: completed by Attending Physician;
• Copy of all lab tests and/or reports;
• Prescriptions;
• Official original Receipts with an itemized or detailed breakdown of charges. This applies to all pay and claim situations, but is not necessary when direct billing service is used.

Further documents may be required for claims involving Accidents or Alternative Treatments. See details below:

Claims involving an Accident:

• Police Report (for traffic accident);
• Incident Report Form: completed by Claimant (for all other accidents);

Claims for Physiotherapy/Chiropractics/Accupunture/Chemotherapy/Radiotherapy:

• Treatment Plan Form: completed by Attending Physician (as form);
• Progress Report: completed by Attending Physician (when a new treatment plan is required after finishing the previous treatment plan).

In-patient Claims:

• Discharge Certificate.

Note: Pacific Cross Insurance may require further documents which is necessary for the claim to be processed and completed.

3. Dental claims (optional benefit):

Required for submission of the first dental claim

• An Oral Examination Report: completed by Attending Physician/Dentist, required for submission of the first dental claim;

For all ensuing Dental Claims:

• Dental Examination Report: completed by Claimant and Attending Physician/Dentist;
• Official original Receipts with detailed and breakdown of charges.

4. Personal Accident claim (optional health insurance policy benefit):

• Death Claim Form: completed by the Beneficiary;
• Attending Physician’s Statement for Death Claim: completed by Hospital/Attending Physician giving details on the nature of the injury or extent and period of disability;
• Police Report;
• Official original Receipts with detailed and breakdown of charges;
• Copy of Declaration of Death or Death Certificate.

B. TIMELINES FOR CLAIM SUBMISSION:

• Travel Claim: within 30 days from the policy expiry date;
• Personal Accident Claim: as soon as possible and not exceed 45 days from the incurred date;
• Health insurence claims should be sent to us as soon as reasonably possible and in any event notification of a claim should be given within 30 days of the loss or incursion of expence;
• Additional document submissions should be done within 90-days after a loss or claim is incurred;
• Failure to submit a claim will not affect the claim if it was not possible or reasonable to submit it on time, in any event claims must be submitted within 365 days of loss or incurred date in order to be accepted by the company.

C. TIMELINES FOR CLAIM RESPONSE:

Pacific Cross Insurance will adjudicate claims within 5 working days from the date of receiving all required documentation and information.

D. CLAIM PAYMENT:

• In cash or by telegraphic transfer in USD;
• Local currency reimbursement is available in some territorries, but cannot be guaranteed;
• Claimant must show recognized photo ID or Passport to receive cash at our offices;
• Any other authorized person must obtain Authorized Letter and copy of the passport of the Claimant to receive claim payment on behalf of a claimant.

E. REJECTION:

In case of claim payment rejection, a denial letter will be sent to the Claimant clearly stating the reason for rejection.

F. ASSISTANCE SERVICES

In an Emergency situation, please call to our Hotline 24 hours/7 days a week:

(+852) 2807 1728

As part of the enrollment with your insurance coverage, an Insured Person has access to emergency medical services:

To access the assistance program, simply call the numbers of the Operation Center listed on the Insurance Coverage Card. The Company is responsible for the cost of all assistance services on the provision that the services are provided and or arranged by Pacific Cross Insurance (hereinafter called “PCI”). PCI will answer the phone call 24/7/365 and based on the need will provide the services and consultations needed, either directly or through an International Emergency Services Assistance Company, currently Asia Assistance. PCI uses an international professional Emergency Assistance Services company to ensure the services rendered are of the highest international level of professionalism and quality, to ensure the expertise is medically sound and verifiable. The services can be given in any language anywhere in the world.

SCOPE OF SERVICES

MEDICAL ASSISTANCE

• Telephone Medical Advice

PCI will arrange for the provision of medical advice to the Insured Person over the telephone.

• Medical Service Provider Referral
• PCI shall provide to the Insured Person, upon request, with the name, address, telephone number and, if available, office hours of physicians, hospitals, clinics, dentists and dental clinics (collectively “Medical Service Providers”). PCI shall not be responsible for providing medical diagnosis or treatment.
• Although PCI shall make such referrals, it cannot guarantee the quality of the Medical Service Providers and the final selection of a Medical Service Provider shall be the decision of the Insured Person. PCI, however, will exercise care and diligence in selecting the Medical Service Providers.

• Arrangement of Hospital Admission

If the medical condition of the Insured Person is of such gravity as to require hospitalization, PCI will assist such Insured Person in the hospital admission.

• Monitoring of Medical Condition During and After Hospitalization

PCI will monitor the Insured Person’s medical condition during and after hospitalization, subject to any and all obligations in respect of confidentiality and relevant authorization.

• Delivery of Essential Medicine

PCI will arrange to deliver to the Insured Person essential medicine, drugs and medical supplies that are necessary for an Insured Person’s care and/ or treatment but which are not available at the Insured Person’s location. The delivery of such medicine, drugs and medical supplies will be subject to the laws and regulations applicable locally. The Insured Person is responsible for any delivery costs incurred.

• Guarantee of Medical Expenses Incurred during Hospitalization

PCI can assist the Insured Person by guaranteeing on behalf of the Insured Person medical expenses incurred during an Insured Person’s hospitalization when the hospital expenses exceed US$2,500.

• Arrangement of Emergency Medical Evacuation (covers actual cost)

PCI will arrange for the provision of air and/or surface transportation, medical care during transportation, communications and all usual ancillary services required to move the Insured Person to the nearest hospital where appropriate medical care is available.

PCI will arrange for the provision of appropriate communication and linguistic capabilities, mobile medical equipment and medical escort crew.

• Arrangement of Medical Repatriation

PCI will arrange for the return of the Insured Person to the Country of Residence following the Insured Person’s Emergency Medical Evacuation and subsequent hospitalization outside Country of Residence.

PCI will arrange for the provision of appropriate communication and linguistic capabilities, mobile medical equipment and medical escort crew.

• Arrangement of Transportation of Mortal Remains

Based on the specific plan you have the schedule of benefits will outline the mortal remains provision. For those plans that have this mortal remains benefit, PCI will arrange for the transportation of the Insured Person’s mortal remains to the airport of the Country of Passport or Country of Residence.

• Arrangement of Compassionate Visit (covers one economy class return airfare)

PCI will arrange for one economy class return airfare for a relative or a friend of the Insured Person wishing to join the Insured Person who, when traveling alone, is hospitalized outside the Country of Residence for more than five (5) days.

• Arrangement of Return of Minor Children (covers one-way economy class airfare)

PCI will arrange for one-way economy class airfares for the return of minor children below 16 years old to the Country of Residence if they are left unattended as a result of the accompanying Insured Person’s hospitalization or Emergency Medical Evacuation. Escort will be provided, when necessary.

• Arrangement of Accommodation (covers US$150 per day up to maximum of 5 days)

PCI will arrange for the hotel accommodation of the Insured Person related to an incident requiring Emergency Medical Evacuation, Emergency Medical Repatriation or hospitalization before the Insured Person is fit to fly.

G. GUARANTEES OF PAYMENT

Pre-authorization is required for all claims over $2,500 USD

If you are a Medical Practitioner, Hospital or Clinic and are seeking a Guaranteed of Payment (GOP) for one of Pacific Cross Insurance’s clients, please follow the procedure:

GOP PROCEDURE:

Submitting required document and information:

• A Notification of Claim Form completed by client and attending physician;
• A medical assessment report from the attending physician showing diagnosis, medical history, and recommended treatment;
• Estimated length of stay; Estimated cost;
• A copy of the Insurance Coverage Card showing the name and policy number;A copy of passport.

Waiting for the Company to issue GOP:

After receiving all required document and information, we will respond for a GOP within 4 hours.

Claim procedure:

After giving service to the client, kindly provide us:

• Original Notification of Claim Form completed by client and attending physician;
• An operation report;
• A discharge certificate;
• Copy of GOP;
• Original official receipts with detailed breakdown of charges.

Important information:

• All documents from health care providers have to be on letterhead of the hospital/clinic;
• Once receiving the necessary forms and clarification, we try and process the claim in 5-working days;
• Claims are reimbursed by cash or by bank transfer;
• Pacific Cross Insurance is not responsible for any charges assessed by the banking institutions and this is the client’s responsibility.

H. EMERGENCY EVACUATIONS:

In case of a situation where the clinic or hospital feels an emergency evacuation may be necessary, it is a requirement to involve our emergency assistance company by using the phone number at the back of the Insurance coverage card.

Hotline for emergency Evacuations: (+852) 2807 1728

For scanned and imaged copies of claim files, please send to

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For any further question or clarifications, please contact us via:

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