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  • Allianz Life Indonesia Summary Cashless Claim With Excess Report

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    Abram Mailoa
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    1. Allianz Life Indonesia processed a cashless claim with excess for subscriber Abram Kenides Yatma Mailoa and claimant Astri Lestari totaling IDR8,849,868,000, of which IDR8,566,986,000 was payable and IDR157,500,000 was not payable due to exceeding limits or being ineligible. 2. A bill for the IDR157,500,000 excess amount would be sent to the employer PT. Novosindo Idetama for settlement. 3. For more information on the claim report, contact Allianz Life Indonesia's customer service.

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    H144ONOVOS-00000-2014022553800037

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    1. Allianz Life Indonesia processed a cashless claim with excess for subscriber Abram Kenides Yatma Mailoa and claimant Astri Lestari totaling IDR8,849,868,000, of which IDR8,566,986,000 was payable and IDR157,500,000 was not payable due to exceeding limits or being ineligible. 2. A bill for the IDR157,500,000 excess amount would be sent to the employer PT. Novosindo Idetama for settlement. 3. For more information on the claim report, contact Allianz Life Indonesia's customer service.

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    © All Rights Reserved
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    25 views2 pages

    Allianz Life Indonesia Summary Cashless Claim With Excess Report

    Uploaded by

    Abram Mailoa
    1. Allianz Life Indonesia processed a cashless claim with excess for subscriber Abram Kenides Yatma Mailoa and claimant Astri Lestari totaling IDR8,849,868,000, of which IDR8,566,986,000 was payable and IDR157,500,000 was not payable due to exceeding limits or being ineligible. 2. A bill for the IDR157,500,000 excess amount would be sent to the employer PT. Novosindo Idetama for settlement. 3. For more information on the claim report, contact Allianz Life Indonesia's customer service.

    Copyright:

    © All Rights Reserved
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    of 2

    03/03/2014

    ALLIANZ LIFE INDONESIA


    SUMMARY CASHLESS CLAIM WITH EXCESS REPORT
    AltReg-SubAcc : 2014012510100110-001 Provider Name : RS MEDIKA PERMATA HIJAU
    Reference No : 23/AKT/RSMPH/I/2014 Date Received : 13-Jan-2014
    Policy ID : H144-ONOVOS-00000 Check # : 100-40228001
    Policy Holder : NOVOSINDO IDETAMA, PT
    No. ID/Name ClaimNo Claim Type Date of Service Billed Payable Eligible Benefit Not Payable Code
    From To To Provider
    1 Subscriber: NOVOS-00021 / ABRAM KENIDES YATMA MAILOA
    Claimant:
    NOVOS-00022/ASTRI LESTARI 2014022553800037 Inpatient 03-01-2014 07-01-2014
    INP-DOCTOR'S VISIT (PER DAY) 110,000.00 110,000.00 110,000.00 0.00
    INP-ROOM & BOARD (PER DAY) 1,900,000.00 1,900,000.00 1,900,000.00 0.00
    INP-MISCELLANEOUS (PER DIS) 380,113.00 342,861.00 342,861.00 0.00 ELG-03B,
    PAY-04B
    INP-MISCELLANEOUS (PER DIS) 5,702,255.00 5,456,625.00 5,456,625.00 0.00 ELG-12
    INP-DOCTOR'S VISIT (PER DAY) 127,500.00 127,500.00 0.00 127,500.00 NPA-09B
    INP-DOCTOR'S VISIT (PER DAY) 630,000.00 630,000.00 600,000.00 30,000.00 NPA-09X
    SUB TOTAL : 8,849,868.00 8,566,986.00 8,409,486.00 157,500.00
    Notes: NOT COVERED
    Tagihan ekses klaim:
    1. GP Vs+Spes.Vs Tagih (1x(127.500+155.000)+(2x155.000)+
    (1x165.500)=757.500 Manfaat 4x150.000=600.000 Ekses
    157.500
    ELG-03B : EXS-BENEFIT NOT ELIGIBLE GRAND TOTAL : 1 CLAIM(S) 8,849,868.00 8,566,986.00 8,409,486.00 157,500.00
    ELG-12 : PROVIDER'S DISCOUNT APPLIED
    NPA-09B : EXS-MX LMT
    NPA-09X : EXS-EXCESS CAUSED MAX LIMIT
    PAY-04B : EXS- ADJUSTMENT OF ADV. PAYMENT IN HOSP
    Excess of claim payment please transfered to : PT. Asuransi Allianz Life Indonesia
    Bank HSBC Cabang World Trade Center Jakarta
    8707888800010198 (IDR-Excess of Claim)

    Please be advised that a bill for the excess of claim would be sent to your employer's attention to settle the above

    For further information about this report please contact our customer service officer
    Allianz Tower Jl. HR. Rasuna Said Kawasan Kuningan Persada Super Blok 2, Jakarta Selatan 12980
    1
    Telephone : +6221 2926 8888, Facsimile: +6221 2926 8080, Email : Contactus@Allianz.Co.Id, SMS: 08121 333 66 99, Web Site: www.allianz.co.id
    OP_CLAIM_CASHLESS_SUM_EXS
    PAR:H144/100-40228001/2014022553800037
    03/03/2014
    ALLIANZ LIFE INDONESIA
    SUMMARY CASHLESS CLAIM WITH EXCESS REPORT

    Please be advised that a bill for the excess of claim would be sent to your employer's attention to settle the above

    For further information about this report please contact our customer service officer
    Allianz Tower Jl. HR. Rasuna Said Kawasan Kuningan Persada Super Blok 2, Jakarta Selatan 12980
    2
    Telephone : +6221 2926 8888, Facsimile: +6221 2926 8080, Email : Contactus@Allianz.Co.Id, SMS: 08121 333 66 99, Web Site: www.allianz.co.id
    OP_CLAIM_CASHLESS_SUM_EXS
    PAR:H144/100-40228001/2014022553800037

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