Frequently Asked Questions:

Ans: You can contact your cooperative representative to obtain the policy number. The HMO card will be distributed by 1COOPHealth to your respective cooperative where you can claim your HMO card.

Ans: Normally during your first year of enrollment, pre-existing conditions are not covered. You can have a coverage for pre-existing illnesses after 12 months of continuous membership. Accounts with atleast 100 initial enrollment are entitled to Pre-Existing Condition coverage in the first day of membership.
Ans: You have the option to upgrade or downgrade your plan upon renewal of your coverage.

Ans: You can cancel your membership and request a refund from your cooperative within the first six (6) months from effective date. A Pro-rated computation of refund is based on the unused months of your membership from the time of your cancellation. No refund will be made after 6 months of membership.

Ans: You must renew your coverage within 90 days from expiration date. If you renew your policy beyond 90-day period, it will be reinstated. Upon reinstatement, a new policy number will be generated, and your application will be treated as a new enrollment. As a result, pre-existing illnesses will not be covered on the first 12 months of membership. However, the coverage for pre-existing conditions will be based on the Cooperative’s contract with 1COOPHealth.
Ans: To renew your 1COOPHealth card, simply get in touch with your cooperative representative.
Ans: Reach out to your cooperative representative for assistance. You may also register your policy number by downloading our 1COOPHealth application.
Ans: 1COOPHealth will release the HMO Card of new members 2-3 weeks after we receive the list of enrollments. We will provide a certificate of coverage and together with your valid ID and present to the clinic or hospital upon Availment in the absence of your HMO card.
Ans: Submit a notarized affidavit of lost together with the accomplished ID Replacement Form and pay P250.00 for card replacement fee.
Ans: We are diagnosis-based in covering your availments. Just like other HMOs, 1COOPHealth has certain exclusions. (Ex: pregnancy related cases, take home medicines, personal items, diseases that are declared epidemic or pandemic by the Department of Health, World Health Organization or any recognized health authority)
Ans: Any and all illnesses proven to be related to or is a complication of a certain illness shall share the same Maximum Benefit Limit (MBL).

Ans: It is possible, provided that the patient will have to shoulder the corresponding Room and Board excess fees, incremental costs of laboratory and procedures done, and Professional Fees of 30%.

Ans: For inquiries on benefit coverage, you may call any of our Customer Care Hotlines or our Trunkline No. (02) 8-638-8628. Your medical details and needed procedure will be assessed if coverable (or otherwise) by your health plan.
Ans: All the availments of our members are diagnosis- based and thoroughly evaluated by our medical team prior to giving approval. We follow the Clinical Practice Guidelines wherein we do a ladderized-type of approval. Example: If a member suffers from UTI, the initial test that needs to be done is urinalysis. If the doctor requested an ultrasound as an initial test, customer care people will advise you to have urinalysis first.
Ans: Yes, you may avail 1COOPHealth services even if you don’t have your physical card on hand. Please ensure that you have a copy of your policy number and contact your cooperative to request a certificate of coverage from 1COOPHealth.  You can just present it to our accredited providers.
Ans: Yes, it is necessary to provide a Valid ID during availment for the coordinators/customer care to validate that the person availing is the one entitled for the said benefits.
Ans: All hospitals have an HMO Department. However, we also have coordinators in some hospitals where members may get their LOAs.

Ans: You don’t need to request an LOA from 1COOPHealth before Availment unless it is APE. Accredited providers will coordinate with 1COOPHealth for the approval of Availment and issuance of LOA.

Ans: Based on the Benefits coverage of the member. As an HMO, we follow what we term as Clinic Practice Guidelines (CPGs). CPGs serve as a guide to help decide which tests are necessary or not in the diagnosis of the patient or which should come first before proceeding to other related tests. Note: All Pre-existing conditions/illnesses are covered after 1 year or upon renewal of plan and/or as stipulated in your contract.
Ans: All 1COOPHealth enrollees are entitled to an APE after 3 months of enrollment. A request for an APE schedule is needed 5 days prior to actual Availment. The request for APE should be coursed thru the mother cooperative for proper endorsement to 1COOPHealth. This can be done thru email at medical@chmf.coop.

Ans: Patients don’t need to give any payment before admission as long as there is still remaining benefit limit on his account.

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

a. Occupy a lower room category and no incremental cost will be charged.

b. 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 the second day of confinement.

c. Or you may transfer to another accredited hospital if it is a non-emergency case.

Ans: You will need to shoulder the PhilHealth cost equivalent upon discharge.
Ans: To reimburse, you need to submit the following documents:

a. Original Official Receipt/s, including the Statement of Account (SOA) and its Charge Slips/Itemized billing.

b. Clinical Abstract if surgical intervention was performed and its hispathological report.

c. Operative Record of the case/treatment or admission/ discharge record duly signed by the attending Physician.

Ans: If the requirements are complete, the process of reimbursement and death claim is 30 working days maximum from the date of receipt of all the documents. All the requirements for reimbursement must be sent to 1CoopHealth within 30 days after the date of availment/discharge/death, otherwise it will be forfeited.

Ans: There are forms provided for each claim such as medical reimbursement, death claim, and HIB benefit. Appropriate requirements are stated in each form. It is important that all the necessary information is accomplished to process your claim and all the documents required are submitted.

Ans: We can send the refund of claims to your main branch or we can deposit your claim to your bank account thru bank transfer.
Ans: Members may only avail from accredited doctors at accredited hospital and clinics. However, if there is no accredited provider in the area, a member may reimburse for his/her availment subject to the reimbursement provisions.

a. Reimbursement up to 80% of hospital bills and 100% Reimbursable up to limit based on RUV HMO rate for all availments done in non-accredited providers for areas WITH NO ACCREDITED PROVIDERS.

b. 100% Reimbursable up to limit based on RUV HMO rate for emergency cases (Subject for evaluation).

c. NO Reimbursement will be made for availment done in an accredited provider except for emergency cases (subject for evaluation).

   Note: All Pre-existing conditions/illnesses are covered after 1 year of contestability period or upon renewal of plan and/or as stipulated in your contract.