PM Care Guide

PMCARE SDN BHD
TERMS AND CONDITIONS

FOR
PMCARE PANEL OF
GENERAL PRACTITIONER CLINICS
PMCARE SDN BHD
TERMS AND CONDITIONS OF
PMCARE PANEL OF GP CLINICS
1.0 PANELSHIP
Your clinic shall be appointed to our PMCare (type of panelship).
2.0 CLINIC NAME
The offer for the appointment is for (submitted name of Clinic), hereafter
referred to as the clinic.
3.0 CLINIC ADDRESS
Your clinic business address is:

Submitted address of Clinic line 1
Under the panelship, you are only authorized to conduct business at the above
stated address. The address shall also be considered as your official
correspondence address where all correspondences or notices shall be
addressed. Should there be any changes, you are to advise us supported by
appropriate documentations and approval from authorities. We reserve the right
to reassign the panelship based on the documentations and location provided.
4.0 OWNERSHIP OF CLINIC
The registered and legal owner of this clinic is (submitted Owner of Clinic).
Under the Panelship, you are only authorized to conduct business based on the
abovementioned ownership. Should there be any changes, you are to advise us
supported by appropriate documentations. We reserve the right to re-assign the
Panelship based on the documents provided.
5.0 CLINIC CODE
Your clinic code is (Clinic Code).
The clinic code is exclusive to the appointed clinic and cannot be used to
represent any other clinic, branch or affiliated clinic. Please quote the clinic code
in all your correspondences with us including claims submissions.
6.0 PRINCIPAL DOCTOR
The Principal Doctor for this appointment is (Name of Principal Doctor).
Should there be any changes, you are to advise us supported by appropriate

documentations.
Effective Date: 1/09/2022, Revision 18

PMCARE SDN BHD
7.0 MODE OF OPERATIONS AND SUBMISSION
You shall conduct business through the Internet based PMCare Mediline™ System
supported by PMR Instant Verification System unless otherwise stated.
As a PMCare panel clinic, you are required to have Internet ready computer
system to enable you to implement our Mediline™ system applications before
commencement of the panelship. You are to also subscribe to the Instant
Verification System (currently PMR) as and when approached.
You shall submit all claims through Mediline™ system within the stipulated time
limit. All submissions via Mediline™ system shall be subjected to a nominal
processing fee of RM8.00 for every successful transaction.
Submission of late claims shall be done through late submission section in

Mediline™ and subject to a further processing charge of RM30.00 per
transaction. Claim that exceeded 30 days from the services date shall be barred
from submission. Late submission claim shall be subjected to the rules imposed
by individual payer.
8.0 CLINIC IDENTIFICATION
To facilitate our corporate clients’ employees and eligible dependents

(“Members”) access to your clinic, you are required to display PMCare Panel of
GP Clinics sticker at a prominent place in front of your clinic.
9.0 PROVISION OF SERVICES – MEDICAL ATTENTION, TREATMENT AND

ANCILLIARIES TO PMCARE MEMBERS
You shall provide services only to valid PMCare Members. Kindly render your
services to our Members to the best of your ability and in accordance to your
professional code of ethics. Be guided by your terms of appointment, working
guidelines, exclusions and the limitations of Member’s benefits under PMCare
program.
10.0 PROVIDER AUDIT
As a PMCare panel provider, you shall be subjected to the clinical audits and/or
procedural audits, which shall be performed from time to time to ensure
compliance to the Terms & Conditions and the Working Guidelines.
11.0 MAINTENANCE OF RECORDS AND CONSENT
Your clinic shall maintain record of every PMCare Member seen and treated at your
clinic and obtain consent for the release of medical information for each visit by
requesting the Member or the guardian (for minor) to sign a note of consent.
We reserve the right to review the above stated clinic records for verification of
claims. Your clinic shall provide to us on site review and/or submit to us copy of
record for the purpose. We reserve similar right to request for adequate on-site
visits, interviews with clinic personnel and inspection of documents to

PMCARE SDN BHD
substantiate these claims in a GP Service Provider Audit by giving you a

notice of not less than 24 hours.
12.0 EXCLUSION
Members’ medical benefits coverage under PMCare Healthcare Management

Services Program is subjected to exclusions. These items are not covered or
payable. Kindly refer to Working Guidelines for PMCare Panel of GP Clinics for List
of Exclusion Items.
13.0 CHARGES
Your charges for the services provided to our Members shall be guided by the
agreed schedule of fees under the panelship appointment and prevailing
Schedule of Fees. Please ensure that the charges be made known in writing to
your patients at the end of the clinic visit.
14.0 MEDILINE™ CLAIMS SUBMISSION
14.1 Deadline for Claims Submission
Your clinic is required to submit to us your Mediline™ GP claims within

three (3) days of date of service provided to our member. Claim that is
submitted late shall not be accepted or payable.
14.2 Supporting Documents
Your clinic may require to submit the following document(s) through

Mediline™ (if applicable):
i) Medical or Laboratory Report
ii) HR approval letter for Public Service Vehicle (PSV) License medical
checkup
iii) HR approval letter for medical checkup
iv) HR approval letter for Good Driving License (GDL) medical
checkup
Failure to submit the above absolves PMCare the obligation to pay for the
claim and be subjected to an appeal to the payor with the discretion to
decide on payment. This decision shall be final.
Forms or letters that are incomplete or incorrect or illegible will not be
accepted or payable.
15.0 QUERIED CLAIMS
PMCare reserves the right to query your claims for:
i. Exceptionally high charges as compared to industry benchmarks;

ii. Questionable or inappropriate prescription or procedure, with given
diagnosis and / or claims for exclusion items;
iii. Discrepancy claims reported by patient via Clinic Visit Advice (“CVA”)

PMCARE SDN BHD
You will be required to respond to our query timely i.e. within 1 day for telephone
query or seven (7) days from date of letter for written query. PMCare shall make
adjustment on the submitted charges based on these responses. Failure to
response absolves the right to object to these adjustments.
16.0 DEDUCTIONS FROM AMOUNT CLAIMED
Deductions might be made from:

i. Exceptionally high charges as compared to industry benchmarks;
ii. Adjustment to charges arising from each claim considered inappropriate
from Queried Claims:
iii. Penalty of RM30.00 for discrepancy claim reported by patient via CVA and
proven it was wrong doing by your clinic;
iv. Service charge for claims successfully received, processed and approved for
payment at prevailing rate per claim;
v. RM0.10 MEPS-IBG charge or RM5.00 Rentas charges by the bank for the
payment made by PMCare via MEPS-IBG or Rentas; and
vi. RM30.00 per claim for late submission claim processing charges.
17.0 GP CLAIMS SETTLEMENT
PMCare shall accept and process your claims for reimbursement that are complete
and timely as per Clause 14.0. We shall pay the accepted claims within 60 days of
receipt, except for the following items:
i. Treatment provided to non-valid member;
ii. Exclusion items;
iii. Medical examination conducted without proper authorization and
incomplete documents; and
iv. Claims queried by PMCare (Clause 15.0)
The payment for queried claims shall be made within 60 days after the queries had
been satisfactorily responded to and rectified by your clinic. Item (iii) and those
awaiting documentations (Clause 14.0) shall be deemed payable 60 days on receipt
of the complete documents. Items (i) to (ii) shall not be payable.
18.0 MODE OF PAYMENT
Payments to your clinic shall be made through our Inter-Bank GIRO (IBG) payment
system or any other electronic banking payment system that we may introduce
from time to time.
19.0 UNINTERRUPTED SERVICE
You shall provide uninterrupted service to our Members except for period of
temporary suspension of service (see Clause 20.0). You shall not deny medical
attention to our Members or collect cash for services covered under PMCare
Healthcare Management Services Program.
PMCare views rejection of Members and collection of cash from Members

for items covered by PMCare Healthcare Management Services Program
very seriously and reserves the right to terminate any panel clinic that
does so.
PMCARE SDN BHD
20.0 TEMPORARY SUSPENSION OF SERVICE
Both the clinic and PMCare may suspend the panelship appointment for a
temporary period of time by giving either party thirty (30) days written notice
before the suspension.
21.0 PROVISION OF SERVICES FOR UNCOVERED ITEMS
At your discretion, your clinic may provide services to our Members for items not
covered under PMCare Healthcare Program and you shall collect the fee for the
service from the Member strictly on Doctor to Patient basis. However, you shall
take due care to explain to the Members of this Clause in order not to prejudice
the business arrangement of the panelship.
22.0 CONFIDENTIALITY
All medical records of Members shall be kept strictly confidential and shall not be
released to any third party except to PMCare where consent for release of
information should have been earlier obtained from the Member.
Both your clinic and PMCare shall also keep all information in relation to the
business arrangement under the panelship strictly confidential.
23.0 CHANGE IN PRINCIPAL DOCTOR, CLINIC OWNERSHIP, CLINIC NAME

AND BUSINESS ADDRESS
When there is any change in the principal doctor, ownership or major

shareholder of clinic, and/or business address, you are required to inform
PMCare in writing one (1) month in advance of the intended change requesting
for our approval of the change together with the relevant supporting documents.
PMCare reserves the right to terminate the appointment if for any reason PMCare
finds the intended change is unsuitable.
24.0 CHANGE IN OPERATING HOURS AND FACILITIES
Your are required to inform PMCare in writing one (1) month in advance of any
intended change in the clinic operating hours or the facilities offered.
25.0 REGISTRATION OF PRACTICE
You shall ensure that your clinic is duly licensed as required by the Private
Healthcare Facilities and Services Act (1998) and Regulations (2006) and a copy
of the license shall be submitted to PMCare.
You shall also provide PMCare a certified copy of your principal doctor’s valid
Annual Practice Certificate (APC) every year not later than 31st of May. You shall
also ensure that all medical practitioners engaged by you have valid APCs and
are registered with Malaysian Medical Council (MMC). You shall provide a
certified copy of the Full Registration Certificate of all above when requested for.

PMCARE SDN BHD
26.0 REGULATIONS
You shall comply and abide to the rules and regulations set forth by the Ministry
of Health and other governing regulatory bodies.
27.0 APPELLANT
If there is any grievance on matters related to the panelship arrangement by

either party, the clinic or PMCare shall give written notice to the other party
(addressed to either the Principal Doctor for the clinic or the Medical Director for
PMCare) giving the respondent seven (7) days to respond. Whilst resolving the
grievance, the complainant may opt to temporary suspend the panelship as
provided under Clause 20.0.
28.0 TERMINATION
Either party, the clinic or PMCare, can terminate the panelship appointment by
giving thirty (30) days notice prior the termination. At termination of panelship
you are required to return to PMCare all properties, which belong to PMCare such
as panelship display sticker and PMCare MyKad Reader (“PMR”) device.
PMCare also reserves the right to terminate your panelship when we deem
necessary without obligation of providing reason.
29.0 WORKING GUIDELINES
You shall be subjected to the Working Guidelines for PMCare Panel of GP Clinics,
attached herewith. The Working Guidelines describes in details the working
arrangement under the panelship appointment. Kindly be guided by and make
reference to it whenever required.
The Working Guidelines is subject to revision which will be updated from time to
time in Mediline™.
30.0 CONDITIONS PRECEDENT TO APPOINTMENT
The following conditions shall be satisfied prior to your appointment as PMCare

Panel of GP Clinics:
i. Acceptance of Letter of Offer for appointment;
ii. Attendance to a PMCare Panel Clinic Induction Program (unless
exempted);
iii. Proven on-site connection to Mediline™; and
iv. Willingness to use PMR Instant Verification System with computer onsite.

PMCARE SDN BHD
WORKING GUIDELINES
FOR
TABLE OF CONTENT PAGE
Chapter 1 - PMCARE WORKING ARRANGEMENT FOR GP CLINIC

1.1 Introduction 1
1.2 Panelship 1
1.3 Principal Doctor 1
1.4 Clinic Address 1
1.5 Clinic Code 2
1.6 Access To PMCare Mediline™ System 2
1.7 Clinic Identification 2
1.8 Modes of Identification of PMCare Member 3-4
1.9 Medical Record 4
1.10 Diagnostic Investigation 4-5
1.11 Maternity Coverage 5
1.12 Referrals 5
1.13 Exclusions 5
1.14 Charges 6
1.15 GP Claim Submission 6
1.16 Submission Deadline 6-7
1.17 Communication 7
Chapter 2 - PMCARE PANEL OF GP CLINIC STICKER 8
Chapter 3 - PMCARE MEMBERSHIP CARDS

3.1 Membership cards for PMCare Open Panel Sticker 9
3.2 Membership cards for Co-Payment Program 10
3.3 Membership cards PMCare Premier Card (VIP) 10
3.4 Membership cards Takaful Malaysia PMCare Card 10
Chapter 4 - LIST OF EXCLUSIONS 11-12
Chapter 5 - RECOMMENDED FEE SCHEDULE 13-15
Chapter 6 - IMMUNISATION CHARGES 16
Chapter 7 - DIAGNOSTIC INVESTIGATION

7.1 The Necessity of A Diagnostic Test 17
7.2 Filling in Your Clinical Diagnostic Request Form 17
7.3 Communicating With Pantai Premier Pathology (PPP) 18
7.4 Making A Laboratory Investigation Claim for Manual Submission 18
7.5 Making a Laboratory Investigation Claim for Your Services 19
Chapter 8 - CLAIMS SUBMISSION

8.1 Mediline™ Claims 20
8.2 Submission of Mediline™ GP Invoicing Listing 20
Chapter 9 - GUIDELINES FOR MEDILINE™ CLAIM SUBMISSION 21-27
Chapter 10 - PMCARE WORKING GUIDELINES: SUMMARY 28
APPENDIXES:
APPENDIX 1 - DIRECTORY FOR MEDICAL DEPARTMENT STAFF 30
PMCARE SDN BHD
WORKING GUIDELINES FOR PMCARE PANEL OF GP CLINICS
CHAPTER 1
1.0 PMCARE WORKING ARRANGEMENT FOR GP CLINIC
1.1 INTRODUCTION
The Working Guidelines is issued with the intention to provide clear description
of the Terms and Conditions and the working arrangement between panel clinic
and PMCare. Both clinic and PMCare are required to observe and comply with the
Working Guidelines. Kindly take time to familiarize yourself with the Working
Guidelines, which should also be made as reference for your daily operation.
Whilst every effort has been made to ensure the Working Guidelines is complete,
comprehensive and simple, it is still subject to further improvement and revision
from time to time for which, you will be informed. Lastly, we will also appreciate
any feedback on the Working Guidelines from you.
1.2 PANELSHIP
Your clinic must be appointed to PMCare Sdn. Bhd. (“PMCare”) Panel of General
Practitioner (GP) Clinics and the appointment status is valid.
There are 2 types of PMCare panel of GP clinics, namely:

i) PMCare Open Panel; and
ii) PMCare Closed Panel such as PMCare-CIMB Bank Panel of GP Clinics.
A clinic can either be appointed to only PMCare Open Panel or to a combination

of PMCare Open and Closed Panel. Our appointment letter will indicate the type
of panelship your clinic is appointed to.
1.3 PRINCIPAL DOCTOR
The principal doctor for your clinic’s appointment to PMCare Panel of GP Clinic is
specified in the appointment letter. When there is any change in the principal
doctor and/or clinic’s ownership, or other items in clause 23.0 and 24.0 under
the Terms & Conditions of Appointment, please notify us in writing 1 month prior
to the intended change together with the relevant supporting documents. We
reserve the right to terminate your clinic’s appointment on the panel if for any
reason to us we find that the intended change is unsuitable for our business
arrangement.
1.4 CLINIC ADDRESS
The clinic appointed to our panel is as specified in the Terms and Conditions of
Letter of Offer of Appointment. During the term of appointment you shall operate
at the appointed address.
If there is any change in the clinic address, you are required to notify us in
writing one (1) month prior to the intended change together with the relevant
supporting documents. We reserve the right to terminate your clinic’s
appointment on the panel if for any reason to us; we find that the intended new
business location is unsuitable for our business arrangement.
Effective Date: 1/09/2022, Revision 18 1

PMCARE SDN BHD
CHAPTER 1
1.5 CLINIC CODE
Your clinic shall be given a PMCare clinic code, which shall be specified in your
appointment letter. Please note that the clinic code is exclusive to the appointed
clinic and shall not be used to represent any other clinic, branch or affiliated
clinic.
The clinic code shall help facilitate communication and help administer the
business arrangement between clinic and PMCare.
1.6 ACCESS TO PMCARE MEDILINE™ SYSTEM
1.6.1 Mode of Operation
You shall conduct business through PMCare Mediline™ system.
As a PMCare Mediline™ clinic, you are required to have Internet ready computer
system to enable you to implement our Mediline™ system applications. Our
application is best viewed in Google Chrome version 55 and above and can be
accessed through our portal https://www.mediline.com.my/.
1.6.2 First Time Log In
Please log on to our web site https://www.mediline.com.my/.
User ID: 101399

Password: PSWD101399
For security reason, you are advised to change the assigned password.
Please familiarize yourself with the system by reading the Guidelines For
Mediline™ Claim Submission (Chapter 9). If you have further query,
please call us for assistance.
1.7 CLINIC IDENTIFICATION
1.7.1 PMCare Panel of GP Clinic Sticker
To facilitate our Members identify and access our panel clinics, all appointed
clinics shall be identified by PMCare Panel of GP Clinics sticker. PMCare Panel of
GP Clinics sticker should be displayed at all time during the term of appointment.
The PMCare Panel of GP Clinics sticker shall remain the property of PMCare at all
times and shall be returned to us if your panelship is terminated for any reason.
Please refer to Chapter 2 for samples of our existing PMCare Panel of GP Clinics
sticker.
1.7.2 How to Display Sticker
Please display the PMCare Panel of GP Clinic sticker at a prominent place and
most visible to public at the front area of your clinic such as the glass door or
window panel. If in doubt of the position of display, please clarify with us.

PMCARE SDN BHD
CHAPTER 1
1.8 MODES OF IDENTIFICATION OF PMCARE MEMBER
1.8.1 Types Of Identification (ID)
PMCare Member may be given a PMCare Membership Identification “ID”.

However he/she is required to produced the National Registration Identity Card
(“NRIC”) whenever requesting for medical attention or service at the panel
clinics. When appropriate, a PMCare smartcard is issued.
The following are examples of existing PMCare Member ID:
i) Membership Card
a) PMCare Closed Panel Program
b) PMCare Open Panel Program
c) PMCare Select Access Program
d) PMCare Co-Payment Program
e) PMCare Smart Card
f) PMCare Premier Card (for VIP members)
g) Takaful Malaysia PMCare Card
ii) Medical Logbook
a) Limited Panel of GP Clinics Medical Logbook
The medical logbook will specify the name of clinics, which allow the
Member to visit. Only GP clinic(s) specified in the logbook is (are)
allowed to provide services to the Member under the program.
b) Limited Number of Visits Medical Logbook
The medical logbook will specify the type of panel and the
maximum number of visits per annum the Member is allowed to
visit under the program. GP clinics are required to verify that the
Member has not utilized the maximum number of visits before
providing service to the member (patient) under the program and
record in the medical logbook each time service is provided to the
member.
Please note that from time to time, PMCare may introduce new modes of
identification of PMCare members. Your clinic shall be duly informed. We
have already embarked on the use of MyKad or/and MyKid for member
identification along with PMCare MyKad Reader (PMR) as a device
connecting to Internet for easy and safer member verification.
For samples of existing modes of identification of PMCare members,

please refer to Chapter 3 - PMCare Membership Cards.
1.8.2 Verification of Member
When a Member seeks for medical services at your clinic, kindly request for the
National Registration Identity Card (“NRIC”).
PMCARE SDN BHD
CHAPTER 1
i) Verification of Members using PMCare MyKad Reader (PMR)
MyKad or MyKid, presumably not defective, can be used with a device

connected to a personal computer that is again connected to Internet.
When appropriate, a PMCare smartcard is issued and this can be used in
place of MyKad/MyKid.
ii) Verification of Members For PMCare Mediline™ System
Please key in either the membership number or identity card number

(old/new). Note that the dependants (spouse and children, where
applicable) eligible for coverage are listed under the Employee. For details,
please refer to Guidelines for Mediline™ Claim Submission (Chapter 9).
1.8.3 When in doubt as to the eligibility of the individual as our member, please
call our Careline to avoid unnecessary denial of service.
1.9 MEDICAL RECORD
Your clinic shall maintain record of every PMCare Member seen and treated at your
clinic and obtain consent for the release of medical information for each visit by
requesting the Member or the guardian (for minor) to sign a note of consent.
Your clinic’s record shall include the following:

i) Member / Patient name and details
ii) PMCare membership number
iii) Date and time for each visit
iv) Consent for the release of medical information
v) Medical condition
vi) Treatment and service rendered
vii) Results of diagnostic tests and procedures, if any
viii) Note on referral, if applicable.
We reserve the right to review the above stated clinic records for verification of
claims. Your clinic shall provide to us on site review and / or submit to us copy of
record for the purpose.
1.10 DIAGNOSTIC INVESTIGATION
In the course of treatment to our Member, it may be necessary for you to

require the Member to undergo diagnostic investigation. The diagnostic
investigation must not be general screening in the nature and the results of the
investigation must assist you in making diagnosis for the Member.
Imaging techniques are confined to plain X-rays. Ultrasound scans are allowable
only in antenatal follow-ups in a valid Maternity Program.

PMCARE SDN BHD
CHAPTER 1
When there is a need to conduct the diagnostic investigation, kindly request for
written approval from PMCare by faxing to us ‘Diagnostic Investigation Request
Form’ (see Chapter 7).
For Laboratory investigation: After conducting the diagnostic investigation, you

are required to follow the GP Claim Submission procedure contained herein when
making your claims for reimbursement.
1.11 MATERNITY COVERAGE
Limited Members do enjoy maternity healthcare benefit.
To check whether Member prenatal and/or post-natal visits are covered at GP panel
clinic, kindly verify member entitlement in Mediline™ to avoid non-reimbursement
from PMCare.
Please take note that in most cases for the first seven (7) months of pregnancy,
treatment can only be done at GP clinic and referral to specialist maternity care
is only permitted in the third trimester, unless in cases of complications.
1.12 REFERRALS
In the course of Member medical management, you may require to refer

Member to other medical practitioners or facilities. Member referral should be
done strictly based on your professional judgment and in the interest of best
practice of medical management. Referral should not be made based on pressure
from Member. Please familiarize yourself with Member’s eligibility for referral
either to government or private facilities. Referral Letter To Specialist can be
issued to a Member via Mediline™.
For Maternity cases, referral to specialist care can only be done for patient in the
third trimester unless in case of complications.
1.13 EXCLUSIONS
Member healthcare benefit under PMCare program is subjected to exclusions

(refer to List of Exclusion - Chapter 4). Please familiarize yourself with the
exclusions and refrain from providing them.
Please take note that ultrasound, sonotron, ozone and chelation

therapy; and any other mode considered NOT evidence-based are not
included in the type of treatment allowed under the panelship
arrangement and if conducted the charges shall not be claimable from
PMCare.

PMCARE SDN BHD
CHAPTER 1
1.14 CHARGES
You should be guided by the agreed schedule of charges under the appointment
to PMCare Panel of GP Clinic and prevailing Schedule of Fees, whichever is lower
when invoicing for services provided to our Members. You are also required to
provide details of services provided together with their respective charges.
1.15 GP CLAIM SUBMISSION
Claims submission shall be done through PMCare Mediline™ Internet application

module. Please ensure that the Mediline™ module is in order.
Please follow on-line instruction and refer to Guidelines for Mediline™ Claim
Submission (Chapter 9) or our Provider Network Management Executive for
further assistance. Your clinic is also required to submit to us copy of the
authorization letter for medical examination, lab test result and / or X-ray report
whenever applicable. Kindly refer Chapter 7 (Clause 7.1 to 7.5).
Please provide the following details:

1) Medical condition and/or diagnosis and treatment given.
2) Medication – describe prescription(s), drug name, dosage, amount
dispensed and itemized cost.
3) Injection – give drug name, dosage and route of delivery.
4) Nebulizer – give the drug (nebulizer fluid) name(s), time of nebulizer given.
5) Toilet and suturing – indicate the number of sutures used.
6) Dressing – indicate the type of dressing done. E.g. Eusol dressing.
7) Minor surgery – indicate the nature of surgery. E.g. excision of ganglion.
8) Other treatment procedures such as removal of foreign body, ear syringing,
suction. Indicate the type of procedure done with brief description.
9) X-Ray – indicate site and view(s) and attach a copy of the report.
10) Laboratory diagnostic that is necessary for the medical condition and not
general screening in nature. Indicate type of lab test and attach a copy of
the lab result.
11) Medical (sick) leave certificate – please provide MC to deserving case and
indicate number of days clearly.
12) Medical examination – indicates the type of examination and attaches copy
of the employer’s or PMCare authorization letter with the copy of the lab
result.
13) Please indicate your clinic code as a reference.
1.16 SUBMISSION DEADLINE
Mediline™ System
Kindly ensure accuracy and submit claims within 3 days of obtaining

Authorization Code (AC). Submission of late claims shall be done through late
submission section in Mediline™. As a deterrent PMCare shall charge RM30.00
per claim as processing charges. Nevertheless, PMCare shall not be obliged to
accept and pay claims that are submitted late i.e. beyond deadline for
submission.

PMCARE SDN BHD
CHAPTER 1
Note:
Please also see:
- Chapter 8 – Claims Submission
- Chapter 9 – Guidelines for Mediline™ Claim Submission
1.17 COMMUNICATION
Please direct any enquiries, complaints or any form of feedback directly to

PMCare and not to our clients, be it its employees and/or dependents. Kindly
communicate with our Provider Network Executive or Medical Director for any
inquiry (refer to Chapter 11 – Directory for Medical Department Staff). Your
email address would be greatly facilitating communication between both parties.
Remember to quote your clinic code each time communicating with us.

PMCARE SDN BHD
CHAPTER 2
2.0 PMCARE PANEL OF GP CLINIC STICKER
The following are samples of our existing logos:
2.1 PMCare Open Panel Sticker

PMCARE SDN BHD
CHAPTER 3
3.0 PMCARE MEMBERSHIP CARDS
3.1 Membership cards for PMCare Open Panel Sticker
3.1.1 PMCare Open Panel Program
1. PMCare – Open panel membership card.

2. Valid in all PMCare – Open panel clinics
3. If you are NOT APPOINTED as PMCare Open
panel clinic, please COLLECT CASH from
member for GP treatment.
PMCare Medical Card
1. PMCare Medical Log Book.

2. Valid in all PMCare – Open panel clinics
3. Limits for benefit shall be specified under
column Coverage Plan Limits (if applicable)
4. Please stamp and sign for every visit.
5. Please indicate amount incurred for each
visit at the column provided.
6. If you are NOT APPOINTED as PMCare Open
panel clinic, please COLLECT CASH from
PMCare Medical Log Book
3.1.2 PMCare Select Access Program
1. PMCare – UMW membership card.

2. The UMW member selected 2 clinics as their panel
that appears on the membership card.
3. Valid only in SELECTED PMCare Open panel clinics.
4. If you are NOT SELECTED as PMCare-UMW select
access program, please COLLECT CASH from
PMCare - UMW Medical Card

PMCARE SDN BHD
CHAPTER 3
3.2 PMCare Membership cards for Co-Payment Program
1. Please collect RM5 direct from the member by

reminding him/her of the wording “Co-
Payment RM5” on the card.
2. Provide treatment as required subject to
Working Guideline.
PMCare – Co-Payment Program
3.3 PMCare Premier Card (VIP)
1. Please verify member based on the NRIC no

displayed on the card.
2. All type of treatment and medication are
covered for Premier Card holder.
3.4 Takaful Malaysia PMCare Card
1. Please verify member based on the NRIC no

displayed on the card.
2. Provide treatment as required subject to
Working Guideline.

PMCARE SDN BHD
CHAPTER 4
4.0 LIST OF EXCLUSIONS
4.1 List of Standard Exclusions
Following is the list of conditions and situations not covered by PMCare’s

Clients at the panel GP Clinics:
4.1.1 Pre-existing Conditions or hospital confinement occurring within the first thirty
(30) days from the commencement of this Certificate due to illnesses unless
the Person Covered affected by these conditions has been covered under this
Certificate for twelve (12) months or has been continuously covered under a
group hospital and surgical takaful or insurance immediately prior to the
commencement of this Certificate.
4.1.2 Congenital abnormalities or physical defects present at birth.
4.1.3 Treatment arising from pregnancy which shall include childbirth and any
complication resulting from pregnancy, miscarriage except as a result of an
accident, diagnostic test for pregnancy, test to do with and treatment for
subfertility or infertility, abortion or sterilisation and contraception; or sexual
dysfunction from any cause including any complications relating thereto.
4.1.4 All forms of outpatient physiotherapy treatment, preventive care including

routine health checks, charges for private nursing, precautionary services,
acupuncture, chiropractic, homeopathy treatment, services received in
convalescent and nursing home, nature cure clinics, isolation or quarantine
by law from any communicable diseases.
4.1.5 Charges which are not for actual necessary and reasonable expenses incurred
in the treatment of the illness or injury, charges for telephone ,television,
news papers and other non medical items.
4.1.6 Eye tests, refractive errors for eyes, expenses for procurement or use of
special braces or prosthesis including spectacles, hearing aids, wheel chairs
and lenses.
4.1.7 Dental care, treatment or surgery unless necessitated by injury caused by

accident.
4.1.8 Treatment or surgery for tonsils, adenoids, hernia or a disease peculiar to the
female generative organs unless the Participant has been continuously
covered under this Certificate for a period of more than one hundred and
twenty (120) days.
4.1.9 Treatment for obesity ,weight reduction or weight improvement ,circumcision,

any elective surgery or treatment which is not medically necessary ,cosmetic
or plastic surgery for the purpose of beautification.
4.1.10 Treatment arising from any geriatric, psychogeriatric conditions, or

treatment to improve the psychological, mental or emotional well-being,
abuse of drugs or alcohol.

PMCARE SDN BHD
CHAPTER 4
4.1.11 Expenses incurred for donation of any body organ by the Person Covered
and costs of acquisition of the organ including all costs incurred by the
donor during organ transplant.
4.1.12 Expenses which are payable under the Workmen’s Compensation or other
insurance or takaful.
4.1.13 Injury or illness occurring directly or indirectly from war (whether war be
declared or not) or warlike operations, invasion, act of foreign enemies,
hostilities, civil war, mutiny, civil commotion assuming the military uprising,
insurrection, rebellion, military or usurped power or any act of the Person
Covered acting on behalf of or in connection with any organization actively
directed towards the overthrow by force of any government or to the
influencing of it by terrorism or violence.
4.1.14 Injury or illness due to directly or indirectly from nuclear weapons material,
ionising, radiations or contamination by radioactivity from any nuclear fuel
or from any nuclear waste from the combustion of nuclear fuel. Solely for
the purpose of this exclusion, combustion shall include any self-sustaining
process of nuclear fission.
4.1.15 Any breach of law by the Participant of any assault provoked by him.
4.1.16 Attempted suicide or self-inflicted injury whilst sane or insane.
4.1.17 Aviation, gliding or any other form of aerial flight other than as a pilot, cabin
crew or fare paying passenger of a recognised airline or charter service.
4.1.18 Participation in or training for any dangerous or hazardous sport or

competition or riding or driving in any form of race or competition.
4.1.19 Acquired Immunodeficiency Syndrome (AIDS), infection by Human

Immunodeficiency Virus (HIV) or related conditions.
Note: Services are to be provided at service providers’ premise. Procedure for

Ultrasound is not payable under GP treatment. Kindly refer the patient to a
specialist clinic for ultrasound. For any medical services that are not covered,
PMCare shall not reimburse and the charges shall be borne by the patient.
(There may be some slight variation in the listed “Exclusions” for some selected
healthcare program depending on our corporate clients’ employee medical benefits.
Please refer to individual listing appended with your appointment letter for each type of
panelship).

PMCARE SDN BHD
CHAPTER 4
5.0 RECOMMENDED FEE SCHEDULE
Item Recommended charges Remarks

All medications are to be entered under individual
diagnosis or diagnoses that tailors with the patient's
presenting medical complaints. Price ceiling is also
implemented and represents a fair and acceptable market
price*. Doctor is required to exercise your clinical
MEDICATION
judgment and should not oversupply the medication. Most
of our clients allow drugs prescription up to maximum of 1
month supply only (especially drugs for chronic diseases).
For clarification, please call the Provider Network
Executive ('PNE') in charge of your clinic.
Minimum RM20 (Exclusive
Antenatal and Postnatal Consultation
of procedures)
RM20 – RM40 depending Only for members with
of type of scans. Picture Maternity Coverage as
Antenatal Scan indicated when member is
printout should be borne
by member. verified using PMR.
Antenatal – Urine (dipstick) RM15
Preferably specimen sent to
RM10 Pantai Premier for restricted
Blood withdrawal for investigation
(Exclusive of actual test) listing of test.
Refer chapter 7.
According to printout size
Chest X-Ray RM35-RM45
inclusive of report
Reflect the amount the client
wishes to bear. Beyond this
Circumcision RM80-RM100
is a matter between the
clinic and the employee.
Prevailing market rate advised with variations based on
Consultation (General) simplicity/complexity and time spent. Quoted amount in
application referred to; clinic to inform if revised.
Depending on size and
location – description (and
Dressing of wounds RM30-45
picture) to substantiate
might be required
Ear syringing RM10-15 (per ear)
RM30 inclusive of
ECG (Resting)
interpretation
Depending on site. Prior
authorization required
giving indication based on
Excision of lumps
history. Proof of familiarity
with procedure may be
sought.
Foreign body removal RM30-RM80 Depending on site
Depending on item injected
Injections RM10-RM45
and site

PMCARE SDN BHD
CHAPTER 4
Intra-articular injection Depending on site. Prior authorization required giving

indication based on history. Proof of familiarity with
procedure may be sought.
Medical Examination New license RM50 Representing client’s
GDL Renew license RM35 willingness to pay
(negotiated) and thus
requires an authorization
letter
Medical Examination Minimum RM40 Negotiated amount as
Pre-Employment agreed by Client prior to
actual examination. Requires
letter from Client or PMCare
Nail Avulsion RM60-RM80
Exclusive of items used.
Nebuliser RM15-RM20
-Bricanyl/Ventolin RM15
-Combivent/Pulmicort RM20
-Duovent/Atrovent/Berotec RM20
PAP Smear RM35
Paraphymosis release RM50-RM70
RBS (Random Blood Sugar) RM10
RM10 for first stitch;
STO
RM5 for subsequent stitch
Urine dipstick RM10

PMCARE SDN BHD
CHAPTER 4
Recommended
Item Remarks
charges
I & D Abscess RM30 – RM50
Excision of cyst/ganglion RM50 – RM100 These procedures need a
brief description of
Toilet & Suturing RM5 per stitch
treatment done. E.g. size
Removal of foreign body and location of abscess,
RM50 – RM80
(Ear/nose/ others) number of sutures and
Dressing RM15 – RM25 details of dressing.
Intra-articular injection RM30 – RM70
Infra red Not covered

Aerochamber Not covered
Sonotron Not covered
Cover only for antenatal
Ultrasound Scan Not covered
scan.
Referral letter fee Not covered
Registration fee Not covered
Disposable (dispensed) Not covered

PMCARE SDN BHD
CHAPTER 6
6.0 IMMUNISATION CHARGES
Age Immunization Recommended
charges (RM)
At birth BCG RM50.00
At birth Hepatitis B (1st dose) RM30.00
2 months Combined Diphtheria-Tetanus-Acellular Pertussis, Hepatitis B, RM180.00
Inactivated Polio and Haemophilus Influenzae type B vaccine
(Hexaxim) 6 in 1
(Hexaxim) 6 in 1
4 months Pneumococcal (1st dose) RM280.00
(Hexaxim) 6 in 1
6 months Measles(1stdose) RM90.00
Pneumococcal (2nd dose) RM280.00
9 months MMR (1stdose) RM90.00
Japanese Encephalitis (JE) (1st dose) RM100.00 - RM150.00
1 year MMR (2nd dose) RM90.00
1 year 3 months Pneumococcal Booster RM280.00
1 year 6 months Combined Diphtheria-Tetanus-Acellular Pertussis, Hepatitis B, RM180.00
(Hexaxim) 6 in 1
1 year 9 months Japanese Encephalitis (JE) (2nd dose) RM100.00 - RM150.00
7 years MMR (Booster dose) RM90.00
13 years Human Papilloma Virus (HPV) (1st& 2nd dose) RM300.00
15 years Tetanus Toxoid Booster (ATT) RM25.00
Overseas Immunization requires letter of authorization from HR

Vaccination Product name Charges
Typhoid Typherix RM55
Vivotif berna (oral) RM60
Meningococcal A&C YW mencevax RM130
Malaria prophylaxis Lariam RM120
Yellow fever RM250
Injection charges Recommended charges

Ampicilline RM20
Bricanyl SQ RM20
Buscopan IM RM15
Chlorpheniramine / Piriton RM15
Dexamethazone RM15
Dimenhydrinate / Stemetil / Maxolon RM15
Gentamicin RM15
Lignocain 1cc RM5
Lincomycin 1cc RM20
Neurobion RM20
Prednisolone / Hydrocortisone RM15
Rocephine 250mg RM40
Triamcinolone / Diprospan RM30 per c.c
Voltaren IM RM20

PMCARE SDN BHD
CHAPTER 7
7.0 DIAGNOSTIC INVESTIGATION
7.1 The Necessity Of A Diagnostic Test
7.1.1 Kindly be reminded that a diagnostic test should not be done at the
patient’s request or as a screening exercise.
7.1.2 All too often in the clinical setting patients ask their provider to bypass
the most fundamental of all diagnostic tools, the history and physical
examination, and advance to the ordering of laboratory testing in a
misguided effort to reassure about their health status.
7.1.3 Providers must take responsibilities for conveying their false impressions
that laboratory test somehow has magic power by them to detect
diseases.
7.1.4 Depending on your requirement, obtain a specimen accordingly, using
appropriate specimen container(s) supplied by Pantai Premier Pathology
Sdn Bhd.`
7.2 Filling In Your Clinical Diagnostic Request Form
7.2.1 Please ensure that the patient is indeed a PMCare member eligible for
the required test in accordance with your practice panel ship.
7.2.2 Fill in the NAME in CAPITAL LETTER followed by the MEMBERSHIP

NUMBER as printed on the card.
Example: MOHD MARZUQ BIN IMRAN

M-M-601325-03-1231-I
7.2.3 Write in your CLINIC NAME and CLINIC CODE preferably as:
EXAMPLE: KLINIK ABCDEFG

PMCare X12345 (clinic stamp)
7.2.4 Tick at the “EMPLOYER” box.

(Please refer to sample for Pantai Premier Diagnostic Form)

PMCARE SDN BHD
CHAPTER 7
Sample for Pantai Premier Pathology (PPP) Diagnostic Request Form
Lab number
Tick the
“employer
” box
Patient name, e.g.: MOHD

MARZUQ BIN IMRAN
(M-M-601325-03-1231-I)
Write your CLINIC

NAME and CLINIC
CODE as:
Clinic Name,
(Clinic Code)
PMCare X12345
(clinic stamp)
7.3 Communicating With Pantai Premier Pathology (PPP)
7.3.1 Inform the nearest PPP’s service office for the specimen collection.
7.3.2 Your specimen will be collected and within 1-5 days the lab report will
be delivered to you at your clinic.
7.3.3 On receiving the result/report, please take note of the Lab Number.
You can appropriately advise your patient of the results.
7.4 Making A Laboratory Investigation Claim For Manual Submission
7.4.1 Pantai Premier Pathology will bill PMCare directly for the diagnostic
tests. Therefore, please do not bill PMCare.
7.4.2 You are allowed to charge PMCare for blood taking procedure/specimen-
handling as follows:
✓ Blood specimens – a flat fee of RM10.00
✓ Urine – nil
✓ Swabs from sites (abscess; HVS) - a flat fee of RM10.00
✓ PAP smears - nil (to be charged as a procedure, at RM20.00)
✓ HPE specimen - nil (to be charged as a procedure, e.g. excision of
lump).

7.4.3 This charge should be written in the column provided for lab test
charges in GP Visit and Consent Form.
7.4.4 Please write in the Lab Number provided on the Lab Report by Pantai
Premier Pathology (PPP) on to the GP Visit and Consent Form in the Lab
(test) Column (manual or the Mediline™ equivalent) as shown below.
Sample on how to write your Lab number into the Manual GP Visit and Consent Form
Write your
Lab No. at
this column
7.5 Making A Laboratory Investigation Claim For Your Services
Submission of a laboratory investigation claim is either through a GP Visit and

Consent Form or through Mediline™. Please ensure that the column for
Diagnostic procedures is filled up for Lab charges. Please attach the copy of the
lab report together with manual GP Visit and Consent Form. If you are using
Pantai Premier laboratory services, please note the Lab No. If we do not receive
the procedure and investigation items done, we may have to contact you and
request the details. Indirectly, this shall delay the claim processing.
Note:
Please also see
- Chapter 1 - Diagnostic Investigation (Clause 1.10)
- Chapter 9 - Making A Laboratory Investigation Claim For Mediline™ Submission,
(Clause 9.2)

PMCARE SDN BHD
CHAPTER 8
8.0 CLAIMS SUBMISSION
8.1 Mediline™ Claims
When you push the “SUBMIT” button your claim is saved into our system
and submission is considered done. There is no need to physically submit
anything.
You are reminded to ensure that the GP Visit and Consent Form is correctly
filled up. All sections of the form must be completed accurately. They must
be kept securely yet be made available should we need to check to
authenticate visits. They should be for a period meeting the statutory
requirement.
It is advisable that the Member verification be made before actual

consultation and claim submission to be made immediately after. However,
it is permissible for the claims to be transmitted to PMCare by the 3rd day
inclusive of the service date. PMCare will not be able to reimburse claims
received after the deadline that is 3 days after the service date.
8.2 Submission of Mediline™ GP Invoicing Listing
All panel clinics are no longer required to submit to us Mediline™ GP

Invoicing Listing to PMCare effective 1 July 2016. You are nevertheless
advised to print this summary of claims for the service month and file it for
easy reconciliation.
Note:
Please also see
- Chapter 1 - GP Claims Submission (Clause 1.15)
- Chapter 1 - Submission Deadline (Clause 1.16)
- Chapter 9 - Guidelines For Mediline™ Claim Submission

PMCARE SDN BHD
CHAPTER 9
9.0 GUIDELINES FOR MEDILINE™ CLAIM SUBMISSION
9.1 Steps on Submission of Claims
Step 1 - How To Access Our Portal
Use Internet Explorer version 5.0 and above or Netscape Navigator version 6.0
and above. Enter our portal at https://www.mediline.com.my/.
Key in your User ID and Password. Click “Login” to go to Step 2.
If this is your first time login, please change your password for security purpose.
The given User ID and Password is regarded as case sensitive. To train your
staff, please use GUEST as User ID and guest2010 as password to avoid
corrupting your claim record and is not meant for actual claim
submission.

PMCARE SDN BHD
CHAPTER 9
Step 2 – Patient Verification Screen
Verify your patients, either by the Member Type (select: Dependent or Member)
or by ID Type, be it a Membership No., New I/C No. or Old I/C No.
If the system states the patient to be an Invalid Member but the membership
card is still valid, please contact our Provider Network Executives (during
office hour) or our Careline (after office hour) to confirm on the
validity.

PMCARE SDN BHD
CHAPTER 9
Step 3 - Authorization Code (AC)
Click “Get Authorization Code” button to get the AC. The AC will automatically
appear at the AC box. To start submitting your claims, click “Proceed to Claim
Entry”.
Don’t forget! Your claim must be submitted within 3 days from the
service date.

PMCARE SDN BHD
CHAPTER 9
Step 4 – Patient Information Screen: How To Submit Your Claims
The verified / authorized member details will be automatically shown on the

screen.
4.1 Key in the visit date and visit time (based on Service Time).

PMCARE SDN BHD
CHAPTER 9
4.2 Key in the chosen Diagnosis from the 30 common diagnosis listing. For
Other Diagnosis, type in the diagnosis in the “Search Diagnosis” box.
4.3 Tick in the treatment information on the medication, itemizing the drugs
names, dosages and duration, which are COMPULSORY. Absence of
these details shall result in delay in your claim processing.
4.4 MC Days. Please enter 0 if no MC is issued.
4.5 To upload supporting document (if required)
4.6 To save, click “Save” button to continue with the next submission. To
check again this claim, go to “Pending Submission” and click at the
claim’s row. The Patient Information screen will appear again.
4.7 To submit this claim straight away, click “Submit & Print Slip”. The
claim will be transmitted into PMCare server.

PMCARE SDN BHD
CHAPTER 10
Step 5 – Report:
5.1 To generate your invoice, click at “Invoice” and “Invoicing”. You need
to key in the “start date”, “end date” to “view invoices.
5.2 You can view your summary of claims by all clients, status of each claims
or report on reason for Excess Not Covered and Rejection under Report
menu.

PMCARE SDN BHD
CHAPTER 10
5.3 To retrieve the payment details, kindly refer to the Payment menu.
9.2 Making A Laboratory Investigation Claim For Mediline™ Submission
9.2.1 Kindly enter the lab charges (individual/package) under lab section
for clinic that did not use Pantai Premier services.
Sample on how to enter your lab charges
Note:
Please also see
- Chapter 1 - Diagnostic Investigation (Clause 1.10)
- Chapter 7 - Diagnostic Investigation
PMCARE SDN BHD
CHAPTER 10
10.0 PMCARE WORKING GUIDELINES: SUMMARY
10.1 PMCare Sticker – Please display your sticker, be it Closed or Open Panel,
prominently as to be seen clearly by the members.
10.2 Verify your Patient – Each Member may present with a valid PMCare membership
card, be it the employee or their dependents. A valid proof of identity, such as MyKad
or NRIC should be sought. We strongly suggest you to verify the Member through
PMR Instant Verification System or Internet (Mediline™). The burden of proof to
verify the validity and eligibility of the Member lies on the clinic on providing the
service. Should you have problem or doubt over the verification process, please
contact us through our 24 hours Careline.
10.3 Treatment and Charges – Kindly render your professional services as deemed
necessary. While there is no limit to the amount charged, you are expected to justify
all items charges and let this be known to your patient. Referral should not be made
at a patient’s request but rather as an exercise of your professional judgment. Please
be aware of your patient’s entitlement when you act on this. Kindly write the referral
letter clearly and advise the specialist concerned to refer back the patient to you as
soon as he/she is stable with appropriate advice.
10.4 Mediline™ - For submission through the Mediline™ please ensure that all
information is provided promptly. Please ensure that all details are entered correctly.
10.5 GP Claim Submission – Submission through Mediline™ should be done daily,

preferably just after the service has been rendered. Claims over three (3) days from
the date of service shall be done through late submission section in Mediline™ and
subject to a further processing charge of RM30.00 per transaction. Claims on persons
not eligible for medical services, incomplete information and wrong clinic code will be
rejected. Note that it is your duty to secure consent for the release of treatment
information to us for claims processing.
10.6 Claim Disputes – Your claims will be scrutinized for validity and appropriateness of
treatment and charges. Claims that are invalid, incomplete, inappropriate will be
rejected and sent back to you with explanatory note of the reasons for rejection. If a
remedy can be offered, we will accept it again for resubmission.
10.7 Claim Reimbursement – Your claims will be processed and payment shall be made
to you within 60 to 90 days after the date of receipt of your claims.
10.8 Uninterrupted Services – You are to provide services without interruption to our
members unless you choose to terminate this services arrangement with us. Such
intention for termination must be notified to us in writing and reach us at least 30
days from the date you plan to stop providing the services. Upon termination, you
are required to remove our panel display sticker.
10.9 Communication – Please direct any enquiry, complaint or any form of feedback
directly to PMCare and not to our clients, be it their employees and/or dependents.
Your email address would be greatly facilitating communication between both parties.

APPENDIX 1
DIRECTORY
NO. NAME TELEPHONE E-MAIL

Dr. Mohd Helmi Ismail
1. 03-8026 6861 drhelmi@pmcare.com.my
Medical Advisor
Rozita Mohamed Noor
2. 03-8026 6876 rozita@pmcare.com.my
Provider Network Senior Manager
Azni Abu Bakar
3. 03-8026 6874 azni@pmcare.com.my
Provider Network Assistant Manager
PROVIDER NETWORK – GP CLINIC UNIT
Azlina Misro
4. 03-8026 7713 azlina@pmcare.com.my
Provider Network Senior Executive
Rosilawati Shafee
5. 03-8026 7712 rosilawati@pmcare.com.my
Provider Network Executive
Mazura Abdul Hamid
6. 03-8026 7714 mazura.hamid@pmcare.com.my
Provider Network Junior Executive
Sarenawaty Md Reduan
7. 03-8026 6866 sarenawaty@pmcare.com.my
Norwatilah Shood
8. 03-8026 6869 watie@pmcare.com.my
PROVIDER NETWORK – DENTAL UNIT
Syazana Abd Azis

9. 03-8026 6865 syazana@pmcare.com.my
Provider Network Executive
PROVIDER NETWORK – HOSPITAL & SPECIALIST UNIT
Nurshafika Othman
10. 03-8026 6872 shafika@pmcare.com.my
Faezah Ibrahim
11. 03-8026 6873 faezahh@pmcare.com.my
Khalidah Kailan
12. 03-8026 6865 khalidah@pmcare.com.my
Nurul Syafiqah Kamarudin
13. 03-8026 6875 nurul.syafiqah@pmcare.my
CARELINE (24 HOURS)
14. PMCare Careline (24 Hours) 03-8026 7799 gl@pmcare.com.my

THANK YOU
FOR YOUR
EXCELLENT SERVICE

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PMCARE SDN BHD

TERMS AND CONDITIONS

Your clinic shall be appointed to our PMCare (type of panelship).

2.0 CLINIC NAME

3.0 CLINIC ADDRESS

Your clinic business address is:

4.0 OWNERSHIP OF CLINIC

5.0 CLINIC CODE

Your clinic code is (Clinic Code).

6.0 PRINCIPAL DOCTOR

The Principal Doctor for this appointment is (Name of Principal Doctor).

Should there be any changes, you are to advise us supported by appropriate

Effective Date: 1/09/2022, Revision 18

7.0 MODE OF OPERATIONS AND SUBMISSION

Submission of late claims shall be done through late submission section in

8.0 CLINIC IDENTIFICATION

To facilitate our corporate clients’ employees and eligible dependents

9.0 PROVISION OF SERVICES – MEDICAL ATTENTION, TREATMENT AND

10.0 PROVIDER AUDIT

11.0 MAINTENANCE OF RECORDS AND CONSENT

Effective Date: 1/09/2022, Revision 18

substantiate these claims in a GP Service Provider Audit by giving you a

Members’ medical benefits coverage under PMCare Healthcare Management

14.0 MEDILINE™ CLAIMS SUBMISSION

14.1 Deadline for Claims Submission

Your clinic is required to submit to us your Mediline™ GP claims within

14.2 Supporting Documents

Your clinic may require to submit the following document(s) through

15.0 QUERIED CLAIMS

PMCare reserves the right to query your claims for:

i. Exceptionally high charges as compared to industry benchmarks;

Effective Date: 1/09/2022, Revision 18

16.0 DEDUCTIONS FROM AMOUNT CLAIMED

Deductions might be made from:

17.0 GP CLAIMS SETTLEMENT

18.0 MODE OF PAYMENT

19.0 UNINTERRUPTED SERVICE

PMCare views rejection of Members and collection of cash from Members

20.0 TEMPORARY SUSPENSION OF SERVICE

21.0 PROVISION OF SERVICES FOR UNCOVERED ITEMS

23.0 CHANGE IN PRINCIPAL DOCTOR, CLINIC OWNERSHIP, CLINIC NAME

When there is any change in the principal doctor, ownership or major

24.0 CHANGE IN OPERATING HOURS AND FACILITIES

25.0 REGISTRATION OF PRACTICE

Effective Date: 1/09/2022, Revision 18

If there is any grievance on matters related to the panelship arrangement by

29.0 WORKING GUIDELINES

30.0 CONDITIONS PRECEDENT TO APPOINTMENT

The following conditions shall be satisfied prior to your appointment as PMCare

Effective Date: 1/09/2022, Revision 18

Chapter 1 - PMCARE WORKING ARRANGEMENT FOR GP CLINIC

Chapter 2 - PMCARE PANEL OF GP CLINIC STICKER 8

Chapter 3 - PMCARE MEMBERSHIP CARDS

Chapter 4 - LIST OF EXCLUSIONS 11-12

Chapter 5 - RECOMMENDED FEE SCHEDULE 13-15

Chapter 6 - IMMUNISATION CHARGES 16

Chapter 7 - DIAGNOSTIC INVESTIGATION

Chapter 8 - CLAIMS SUBMISSION

Chapter 9 - GUIDELINES FOR MEDILINE™ CLAIM SUBMISSION 21-27