Customer Center

Please submit al original bills together with official receipts or the scanned copies and make sure the following information/documents is/are included:
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a) Acompletely filed in "Notification of Inpatient/Outpatient Claim Form"
b) Name of patient, Member No. and Policy No.
c) Date of hospital admission and discharge
d) Diagnosis of disability requiring the hospitalization and name of surgical procedures performed (if any)
e) Itemized charges/detailed breakdown of charges

Please submit al original bills together with official receipts or the scanned copies and make sure the following information/documents is/are included:
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a) "Notification of Inpatient/Outpatient Claim Form" with Name of patient, Member No. and Policy No.
b) Doctor/Service provider name and address including the country where service was rendered
c) Date of treatment/visit with diagnosis or name of injury
d) Detailed breakdown of charges/services with actual charges paid with official receipts
e) Referral letter by the Attending Physician for physiotherapy, diagnostic laboratory tests, x-rays and prescribed medicine is required
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Note: Photocopies or computer printouts furnished by your service provider will not be accepted. For U.S.A. service provider, HCFA-1500 Forms with doctor's signature will be accepted

Please submit:
a) Original bills and official receipts or the scanned copies
b) A completely filled in "Dental Claim Form". The dentist is required to mark the area of oral treatment on the dental chart
c) Itemized charges
d) A completed oral examination report is required for submission of the first dental claim

Please submit:
a) Original bills and official receipts or the scanned copies
b) Hospital/Physician's reports giving details on the nature of the injury and the extent and period of disability, police report where relevant and if death shal have resulted, a completed "Calmi Form - Death", "Attending Physician's Statement for Death Claim", a copy of the death certificate and the relevant coroner's report

Please visit Medical Provider Network to get the map of Direct Billing Facilities which provide Cashless Services to customers of Pacific Cross Indonesia.

Remember: show a valid Coverage Card issued by Pacific Cross Indonesia and photographic ID (or Passport) when visiting a Clinic/Hospital which is in the list of Medical Providers for Direct Billing Services.

Please complete page one of the Notification of Claim Form; request a chance to check your Invoice to ensure all information is accurate and, if possible, sign the Invoice after receiving all medical services.

A claim can be made with the following supporting documentation:

- Notification of Claim form: completed by Claimant and Attending Physician
- Medical Report: completed by Attending Physician;Copy of all lab tests and/or reports Prescriptions
- Official original Receipts with an itemized or detailed breakdown of charges.

This applies to all pay and claim situations, but is not necessary when direct billing service is used.

Further documents may be required for claims involving Accidents or Alternative Treatments. See details below:

Please enclose the following documents to your claim

- Police Report (for traffic accident)
- Incident Report Form, completed by Claimant (for all other accidents)

Please enclose the following documents to you claim

- Treatment Plan Form: completed by Attending Physician (as form)
- Progress Report: completed by Attending Physician (when a new treatment plan is required after finishing the previous treatment plan).

- Discharge Certificate. Note: Pacific Cross Indonesia may require further documents which is necessary for the claim to be processed and completed.
- Death Claim Form: completed by the Beneficiary
- Attending Physician’s Statement for Death Claim, completed by Hospital/Attending
- Police Report
- Official original Receipts with detailed and breakdown of charges;
- Copy of Declaration of Death or Death Certificate.

Travel Claims: A claim file includes following documents:Travel claim form: completed by Claimant;Travel Certificate;Boarding Pass;Copy or scan of all pages of Passport;Copy of air ticket booking;Official original Receipts with a detailed breakdown of charges.Further documents will be required for the following claims:

1. Claim for Baggage Delay:Irregularity Report;Luggage Delivery Report;Official original Receipts with a detailed breakdown of charges.
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‍2. Claim for Travel Delay:An Official Document from the transportation Carrier clearly stating the cause, date, time and duration of the flight delay.
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‍3. Claim for Personal Accident:Police Report;Incident Report: completed by claimant;Attending Physician’s Statement for Death Claim: completed by Hospital/Attending Physician giving details on the nature of the injury or the extent and period of disability;Copy of Declaration of Death or Death Certificate

4. Claim for Medical expenses:Medical Report: completed by Attending Physician;Copy of all lab tests and or reports;Prescriptions;Official original Receipts with a detailed breakdown of charges.

Note: Pacific Cross Indonesia may require further documents which is necessary for the claim to be processed and completed.

Timelines for claim submission:

- Travel Claim: within 30 days from the policy expiry date
- Personal Accident Claim: as soon as possible and not exceed 45 days from the incurred date
- Health insurance claims should be sent to us as soon as reasonably possible and in any event notification of a claim should be given within 90 days of the loss or incursion of expense.

Failure to submit a claim will not affect the claim if it was not possible or reasonable to submit it on time, in any event claims must be submitted within 365 days of loss or incurred date in order to be accepted by the company.

Timelines for claim response: Pacific Cross Indonesia will adjudicate claims within 5 working days from the date of receiving all required documentation and information.

Claim payment: By transfer in US$. Local currency reimbursement is available in some territorries, but cannot be guaranteed.
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For scanned and imaged copies of claim files, please send to
claimsubmission@pacificcross.co.id
‍For any further question or clarifications, please contact us via sales.contact@pacificcross.co.id