This research explains the process of filing a claim, as well as one Indonesian health insurance company’s decision-making process regarding medical claims. The research is descriptive and qualitative, and the data was collected using observations, interviews, and relevant company documents. In the claim submission process, a claim form must be filled out and accompanied by all the required documents. Claims are approved, rejected, or postponed (a pending claim). The decision process for claims includes completing the necessary documents and verifying that the data submitted is accurate. Incomplete documents can cause claim settlements to be postponed. If the customer does not complete the requested documents within 30 days, the claim will be rejected. If submitted information is not valid, if fraud or abuse is indicated, or if a claim includes a policy exclusion, its submission will require further investigation, and a decision about the claim will be postponed. Investigations can be done by contacting the customer, a claim forum, the hospital, or other related parties.
|Advances in Social Science, Education and Humanities Research
|3rd International Conference on Vocational Higher Education (ICVHE 2018)
|2/08/18 → 4/08/18
- filing claims
- claims decision
- health insurance