Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB)

Step 3: Check if member has coverage. 

Step 4: Check patient history 

Step 5: Once the member has already used the procedure it will be denied

Step 6: If the member haven't used. Procedure will be approved

Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB)

Step 3: Check if member has coverage. 

Step 4: Once the member has already used the procedure it will be denied

Step 5: If the member haven't used he/she has remaining sessions to avail it will be approved

Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB)

Step 3: Check patient history 

Step 4: If the member has already avail the procedure request will be denied

Step 5: If the member still not using the procedure, request will be approved

Step 1: Search the name of the member in the system

Step 2: Check if the member is the recipient. If the member is not the recipient request will be denied

Step 3:. If the member is the recipient request will be approved.

Note: Request will be denied because Covid anti gen test is not complementary test by DOH.

Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB)

Step 3: Check if member has coverage. 

Step 4: If not covered request will be denied. 

Step 5: If covered request will be approved

Step 1: Search the name of the member in the system

Step 2: Check patient history

Step 3: If the member has no history. Ask the member if his/her is taking medication. If the member is taking madication request will be approved.

Step 4: If the member is not taking any medication his/her need to take FBS first. Status will be on-hold.

Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB)

Step 3: Check if member has coverage. 

Step 4: If not covered request will be denied. 

Step 5: If covered request will be approved. If the request is already claimed request will be denied

Step 1: Search the name of the member in the system

Step 2: Check if the member is the recipient. If the member is not the recipient request will be denied

Step 3:. If the member is the recipient request will be approved.

Note: Request will be denied because Covid anti gen test is not complementary test by DOH.

Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB) 

Step 3: Check if member has coverage.

Step 4: If there is no modality it will be denied

Step 5: Once the member has coverage of new modality it will be approved. 

Step 1: Search the name of the member in the system

Step 2: Open the Schedule of Benefit(SOB) 

Step 3: Check if member has coverage.

Step 4: If there is no modality it will be denied

Step 5: Once the member has coverage of new modality it will be approved. 

Note: Under general exclusion invalid request.

Note: Under general exclusion invalid request.

Note: Under general exclusion invalid request.