Download
Plsase find below necessary forms for your pre-authorization or claim submission
Pre-authorization Form
Please be aware that, pre-authorization form is a must regardless the pre-authorization is initiated by the member or the hospital unless you have a full medical report. Please find below list of pre-authorization items and follow the online pre-authorization submission to provide all the necessary information.
Claim Form
Claim form is needed when you need to submit a claim for any treatment without direct billing or direct settlement arrangement. Please follow the procedure as below online claim submission and provide all the necessary information. Inadequte information will delay the process of your claim significantly.
Pre-Authorization List
Based on Medical Necessity and Fair Use Policy
For below treatment, please obtain pre-authorization BEFORE carrying out treatment.
· All inpatient treatment, including baby delivery
· All surgical treatment, including outpatient surgery
· All endoscopies
· Imaging test including CT, MRI, PET
· Single exam/test pricing over 5,000 THB
· Purchase or rental of durable medical equipment such as wheelchair, insulin pump, etc.
· First time of cancer treatment or kidney dialysis
· Physiotherapy due to non-accident causes
· Long term prescription over 90 days
Pre-authorization Online Submission
Please use the form on the right side to submit pre-authorization. Please note, pre-authorization is required at least 48 hours before the operation time unless it is emergency situation. Fail to obtain pre-authorization may result a decline or partial deline of your claim. Please note, although some hospitals may provide help to process the pre-authorization on member's behalf, it is still member's liability to make sure Pre-authorization is obtained on time.
Mailbox Number 828
B1 Floor, Emporium (Sukhumvit Road),
Khlong Toei, Bangkok, 10110
Hotline: 064-942-6592
Submit a Claim
Please fulfill all the required information listed as below