Checklist of Claim Reimbursement Documents

Inpatient & Outpatient Benefits:

 Completed claim forms (member’s name, policy number, member number) as written on
insurance card
 Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment, etc
 Original payment receipt
 Detail of medical expense
 Copy of prescription
 Copy of laboratory / diagnostic result
 Claim form recapitulation
 Another supporting documents

Dental Benefit:

 Completed claim forms (member’s name, policy number, member number) as written on
insurance card
 Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment
type, configuration of treated teeth, etc
 Original payment receipt
 Detail of medical expense
 Copy of prescription
 Copy of laboratory / diagnostic result (dental x-ray or panoramic photo)
 Claim form recapitulation
 Another supporting documents

Maternity Benefit:

 Completed claim forms (member’s name, policy number, member number) as written on
insurance card
 Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis symptoms, therapy, treatment, etc
*For antenatal treatment: should be informed gestational age from obstetrician
 Original payment receipt
 Detail of medical expense
 Copy of prescription
 Copy of laboratory / diagnostic result
 Claim form recapitulation
 Another supporting documents
Emergency Outpatient due to Accident:

 Completed claim forms (member’s name, policy number, member number) as written on
insurance card
 Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment, etc
 Original payment receipt
 Detail of medical expense
 Copy of prescription
 Copy of laboratory / diagnostic result
 Claim form recapitulation
 Detail Chronology
 Valid driving license (if member as a driver)
 Policy report letter
 Another supporting documents

Coordination Benefit (CoB) from other insurance

 Completed claim forms (member’s name, policy number, member number) as written on
insurance card
 CoB letter from the 1st insurer which informed member name, claim amount, paid amount,
unpaid amount
 Certified true copy of supporting documents from the 1st insurer as follow:
-Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment, etc
-Payment receipt
-Detail of medical expense
-Prescription
-Copy of laboratory / diagnostic result
 Original receipt of excess claim if the excess paid by member at the hospital (not guaranteed by
the 1st insurer)
 Claim form recapitulation
 Another supporting documents