Subject: [hftn] Further examples of Claims Forms
From: Matthew Jowett via EZcollab <[email-masked]>
To: "WHO Health Financing Technical Network (HFTN Main Community)" <[email-masked]>
Date: Fri, 14 Feb 2020 14:45:34 +0000

The following attachments were removed from this message and stored in the library:

Health Insurance Claim
Form.pdf (0,1MB)

Dear all,

Please see below. Thanks to Lisa from ILO.

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From: Alex Leung <[email-masked]>

Sent: 14 February 2020 15:24

To: Morgan, Lisa <[email-masked]>

Cc: Edward Pudlowski <[email-masked]>; IAAHS Board <[email-masked]>; Adrian Baskir <[email-masked]>

Subject: Re: Request for example of a comprehensive PMI Claims Form

Hi Lisa,

A few examples for Hong Kong and Singapore:

AIA HK: https://www.aia.com.hk/content/dam/hk/pdf/form-library/claims/OPCLMF03.0119_v9._1224_barcode.pdf

Bupa HK: https://www.bupa.com.hk/-/media/files/pdf/bupa-hospital-claim-form.pdf & https://www.bupa.com.hk/-/media/files/pdf/bupa-clinical-claim-form.pdf

Aetna SG: http://www.aetnainternational.com/aiweb/contentMgt/assets/documents/sp/Singapore-AICL-MAS-Claim-Form-Medical-M003-35E.pdf

AIA SG: https://www.aia.com.sg/content/dam/sg/en/docs/form-library/accident-and-hospitalisation-claim-form.pdf

Cheers,

TW +886 908 800 871

HK +852 6770 7459

US +1 510 761 5107

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From: Morgan, Lisa

Sent: Friday, February 14, 2020 3:26 PM

To: Wangari Ng'ang'a ; JOWETT, Matthew

Subject: Example Claims Forms

Dear both,

I have asked around – attached is a private health insurance claims form example and if you follow the link below, you will see what they use for the government health schemes in the US (Medicare
and Medicaid).

I hope this is helpful and will send through anything else that comes back to me.

Best regards,

Lisa

From: Edward Pudlowski <[email-masked]>

Sent: 14 February 2020 15:08

To: Morgan, Lisa <[email-masked]>; IAAHS Board <[email-masked]>

Cc: Adrian Baskir <[email-masked]>

Subject: RE: Request for example of a comprehensive PMI Claims Form

Lisa:

In the US, claims are typically submitted to the insurer directly by the provider (hospital, physician, pharmacy, etc.) so there are very few examples of claim forms, especially in the non-government arena.  However, I did find an example
(attached) from a smaller health plan that must require a claim form for non-participating providers.  Note this form appears to be specific to a non-hospital, physician form.  Hospital based forms in the US would require a different set of codes (ICD-10).
Therefore, I’m not sure how helpful this will be.

The Center for Medicare and Medicaid Services (CMS) does have a standard form for providers.  Here is a link to a site that:

https://cms-1500-claim-form.com/?msclkid=bedcb0ca64991e1c1775ee8cc261e6cb&utm_source=bing&utm_medium=cpc&utm_campaign=PDFfiller_Top_Forms&utm_term=health%20insurance%20claim%20form%201500%20printable&utm_content=*2012%20CMS%201500,%20%5B2012-02%5D.  I did
not go through the entire form but as it is used for Medicare (US social insurance for the aged – over 65) and Medicaid (US social insurance for those below the US Federal Poverty Line) would likely have all of the required elements and cover hospital-, physician-,
and pharmacy-based claims.

I hope this is helpful to you in some way.

Ed Pudlowski,
FCA, MAAA, ASA

President

214-912-7334

MorningStarActuarial.com

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