Oceanic Health Call Centre staff are trained to be polite and courteous but should any agent, in your opinion fall below your expectation, you should formally forward a complaint to email@example.com
You will not be reimbursed for not attending the hospital. Oceanic Health pays the healthcare provider for out-patient services on a monthly basis whether or not you did not go to the hospital and therefore premium paid cannot be reimbursed.
Not all the providers are specialist care providers. An enrollee can be referred to a specialist care provider from his chosen hospital. A specialist care provider under the
Oceanic Health Insurance Scheme is a medical practitioner with Fellowship or Board registration as specialist in Orthopaedics, General Surgery, Internal Medicine, Obstetrics and Gynaecology, Physiotherapy, Ophthalmology, Optometry, Paediatrics, Dentistry and in other recognized medical specialties and who has satisfied the requirements of Oceanic Health Insurance Scheme as having the capacity to do so within expected quality assurance standards criteria prescribed by Oceanic Health, and as thus been accredited to provide the required specialist care.
You can go to any other Oceanic Health provider on our network close to that location and present our ID card, your eligibility will be confirmed, and you would be attended to. You can also call our telephone lines for assistance.
Safe and effective drugs approved by NAFDAC in addition to correct clinical examination, investigation, and diagnosis is what guarantees good outcomes and not branded drugs. Hospital may not be able to store branded drugs that every enrollee will prefer to use. Choice of drug should be left to the discretion of the doctor, although an enrollee has a right to refuse any drug given.
The HMO has an enrollee handbook that is given to every new enrollee and this contains all the information one needs to know but if an enrollee is not clear about some certain issues, calling our Call Centre lines would help to clarify the benefits for each plan.
Only extreme emergency cases attracts re-imbursement, for example, in a situation whereby someone suddenly stops breathing and is rushed to the hospital and oxygen is to be administered, the patient can pay the bills since it’s an emergency, then later on, the HMO would reimburse the patient. However reimbursement is only guaranteed where the enrollee had notified Oceanic Health not later than 48hrs after the incidence.
All claims for the current month are to be sent during the first week of the next month in order to ensure prompt processing of their claims. Also all claims should be prepared following all necessary guidelines.
The best way to get enough enrollees is by treating the currently enrolled very well and following laid down HMO guidelines .This will attract more enrollees by way of referral by your current enrollees
Capitation paid for all enrollees is meant for only treatment of minor ailments that require out-patient treatment .It is meant for all enrollees registered with a provider are supposed to be pooled to treat only those enrollees that will fall sick during the course of the month.
No provider should demand payment for covered services from any enrollee. Providers are to call the Oceanic Health Call Centre Lines to get authorization to treat. No enrollee of Oceanic should be denied medical treatment or asked to pay for covered services. Enrollees who are visiting from other towns are entitled to treatment on out-of-station basis following confirmation of eligibility via our Call Centre. Where not clear all providers should seek clarification on what services are covered under enrollee’s plan and if so indicated obtain appropriate preauthorization.
Hospitals are supposed to request for approval in form of a pre-authorization from the HMO in order for the HMO to monitor the quality and medical necessity of treatment and also assure the hospital of their payment.
Write to the Health Plan Manager stating the circumstances surrounding the payment made out-of-pocket and notification to Oceanic Health within 48hrs of the incidence. Attach all original copies of receipts for payments and your request will be considered based on its merit.
Pre-authorizations are approvals given to healthcare providers for services other than capitation-covered services upon request by the provider. It is the responsibility of the provider to request for pre-authorization and not the enrollee. Pre-authorization helps the HMO to monitor the quality of care and ensure medical necessity of treatment about to be given to enrollee.
Issuance Medical sick leave is subject to the discretion of the attending doctor after assessment of your clinical condition. Issuance of sick leave must be in line with the principle of evidence based medicine and medical necessity.