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Regulations Governing Body Health Social Security Number 4 2016 2016

Original Language Title: Peraturan Badan Penyelenggara Jaminan Sosial Kesehatan Nomor 4 TAHUN 2016 Tahun 2016

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he First Pay

make the payment, or make a replacement

payment to The First payer corresponds to

its obligations.

24. Branch Office Application next called

application BOA is the application that is in the Office

The BPJS Health Branch that displays the bill

claims for health care to Participant at

Facility Health.

BAB II

COORDINATION OF BENEFITS

Part Kesatu

General

Article 2

(1) BPJS Health Insurance and Organizing Health Insurance

Extra can do deep coordination

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provides the Benefits for Health Guarantee

National who have the rights to program protection

Additional Health Insurance.

(2) The purpose of coordinating benefits to ensure Attendees

obtaining its rights as the BPJS Health Participant and

as an Additional Health Insurance Participant accordingly

mechanism applicable to BPJS Health.

Section 3

Coordination in providing Benefits to Participant

National Health Guarantee as intended

in Section 2 is done by BPJS Health with

Additional Health Insurance Organizer who

sells indemnity, cash plan and managed care,

provided

with a provision:

a. BPJS Health as the first guarantor; and

b. Additional Health Insurance organizers as

The first payer.

Article 4

(1) The benefit coordination is enforced if BPJS Participants

Health buys Additional Health Insurance from

The program organizer Additional Health Insurance

which has worked closely with BPJS Health.

(2) The benefit Coordination obtained by the participant does not exceed

the total amount of his health care costs.

Section 5

Insurance Organizer Additional Healthcare that will

carry out cooperation coordination benefits with BPJS

Health must meet the administration requirements as

following:

a. attach a copy of the Operational License;

b. attach a photocopy of NPWP Agency;

c. attach evidence of registration or logging letter

or proof of Health Insurance reporting

issued by the Financial Services Authority;

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d. attach a Statement of Statement that:

1) Additional Health Insurance Organizers

are willing to do cost control

health care services performed by the Facility

Health;

2) Additional Health Insurance organizers are participating in

active participation in prevention efforts

cheating (fraud) in the implementation of the program

Health Guarantee; and

3) Additional Health Insurance Organizers

willing to provide primary health care

for Health Guarantee Participants National which

is warranted with the appropriate scope and quality

with the provisions of the laws.

e. are willing to provide information related to claims data, iuran

and the inclusion of BPJS Healthcare required; and

f. not to be subject to restrictions on business activities

or sanctions ban doing product marketing

health insurance.

g. It is an additional Health Insurance that

national and multinational status in accordance with

provisions of applicable laws.

Second Section

Benefit Coordination and Other Coordination

Paragraph Kesatu

Benefit Coordination

Article 6

(1) The Coordination Of Benefits between BPJS Health with

Additional Health Insurance Organizer can

be given at:

a. FKRTL that works closely with BPJS Health;

and

b. FKRTL that does not cooperate with BPJS

Health.

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(2) The benefit Coordination granted on FKRTL

in cooperation with BPJS Health as

referred to paragraph (1) the letter is performed for

Service awarding the Level Inap Advanced (RITL)

in accordance with medical indications and beyond Non-Specialistic Cases.

(3) The use of the use of the interchange in FKRTL

does not cooperate with BPJS Healthcare as

is referred to in paragraph (1) letter b, only given

emergency conditions.

Second Paragraph

Another Coordination

Section 7

(1) In addition to the Benefit Coordination as referred to in

Section 2, BPJS Health and Insurance Organizer

Additional health can do cooperation and

coordination:

a. Total membership;

b. Socialization;

c. Iuran collection; and

d. information systems.

(2) The ordination of the inclusion as referred to in the paragraph

(1) the letter a includes:

a. Coordinating the participant's registration of the Warranty Program

Health, performed with stage:

1. The entity lists all of its workers

and its Family Members to the Organizer

Additional Health Insurance;

2. Additional Health Insurance organizers

receives registration from the Business Agency for

all of its Members and Family Members;

3. Additional Health Insurance organizers

ensuring the Business Agency has registered

all its Staff and Family Members

as BPJS Healthcare Participants;

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4. Additional Health Insurance alignment

handed the Agency registration file

to BPJS Health; and

5. Additional Health Insurance organizers

reports the participants ' data following

Coordination of Benefits to BPJS Healthcare.

b. Coordinate coordination of less Coordinating participants

Benefits, performed with stage:

1. Entity or Participant may update the data

participants of the Benefit Coordination to Organize

Additional Health Insurance;

2. Additional health insurance organizers

reported the renewal of the Coordinating Participant data

Benefits to BPJS Health; and

3. Additional Health Insurance organizers

publishes a shared Identity Card for Participants

The Benefit Coordination.

(3) The socialization Coordination as referred to in the paragraph

(1) letter b, performed in the form:

a. The active socialization and marketing of the warranty program

national health by the Insurance Organizer

Additional Health; and

b. Shared socialization between BPJS Health and

Additional Health Insurance Organizing to

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The BPJS Health Benefits Coordinating Participant and

Additional Health Insurance Organizer.

18. Guarantor is the party that performs the upper hand

health care for the Participant.

19. The payer is the party that makes the payment

over the bill of health care costs to the Facility

Health.

20. The first guarantor is the first to

perform a copy of the service

health to the Participant.

21. The Second Guarantor is the party that does

the disservice after the reincarnation was done

The First Guarantee.

22. The First payers are the first to

make payment on the service fee bill

health to the health facility.

23. The Second payer is the party that performs

payment on the health care costs bill

to the Health Facility after te:always; page-break-after:always">

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e. Organizer of the outpatient care service

Additional Health Insurance is provided for one

treatment episode.

f. Additional Health Insurance organizers

provide ease in the business

administration administration to Participant.

(7) In the days of care of the service that has been

is given to the Participant as it is In

paragraph (4), paragraph (5) and paragraph (6), Licensee becomes

the responsibility of the Health Insurance Organizer

Additional and unable to switch to the liability

answer BPJS Healthcare.

(8) Insurance Organizing Additional Health in

provides health care benefits to

Participant, mandatory for quality control and control

charges.

Section 12

(1) In case of the Participant having an emergency condition, system as referred to

paragraph (1) d letters performed in the registration process

participants Coordination of Benefits, data changes and mutations

add less participants of the Benefit Coordination.

(6) Further provisions regarding the coordination form

as referred to in paragraph (1) are set in

cooperation agreement between BPJS Healthcare with

Additional Health Insurance Organizers.

Article 8

In terms of the Participant or the Entity Entity to have more than 1

(one) Additional Health Insurance for itself, Workers

and Her Family Member then:

a. the coordination form referred to in Section 6

and Section 7 of the paragraph (1) is only done by one

Additional Health Insurance Host

in collaboration with BPJS Health; and/or

b. Participants or Enterprise can directly

register and payment dues to

BPJS Healthcare without going through the Insurance Organizer

Additional Health.

BAB III

IURAN BILLING MECHANISM

Section 9

(1) The Participant or Entity may make the payment

the Health Guarantee dues through:

a. BPJS Healthcare; or

b. Additional Health Insurance organizers.

(2) In the event of an Participant or an Entity performs

Health Guarantee payments through

Additional Health Insurance Organizer, then

payment of health insurance dues can be done

along with the Insurance premium payment

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Additional Health.

(3) The health insurance coverage provided by

Participants or Effort through Organizing

Additional Health Insurance in accordance with the provisions

laws.

(4) In the event of an Participant or an Entity performs

the payment of health insurance dues through

Additional Health Insurance Organizer

as referred to in paragraph (2), Organizer

Health Insurance Additional mandatory storage

health assurance via Virtual Account Agency

Effort to BPJS Healthcare the slowest of date 10

(ten) each month.

(5) The health insurance coverage is through

Additional Health Insurance organizers

as referred to in paragraph (2), every month

running performed monitoring by BPJS Health.

(6) Technical implementation monitoring as intended

on paragraph (5) is further set up in the Work Agreement

Same.

Section 10

(1) Health Warranty dues may be paid for more

of 1 (one) month performed at the beginning.

(2) In case of the Participant or the Business Agency pays dues

health guarantees for more than 1 (one) month at the beginning

as referred to in paragraph (1), Organizer

Additional Health Insurance is required to provide all

iuran received to BPJS Health.

(3) In case there is an iuran payment delay

Health Guarantee is more than 1 (one) month since

date 10 as it referred to verse (3),

imposed temporary termination sanction pursuant to

the provisions of the applicable laws.

(4) In the event of the Participant or the Effort late

pay the dues as referred to in paragraph (1),

Additional Health Insurance Organizing is mandatory

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invoice the health guarantee dues to the Participants or

Entity ID.

(5) The order of the reactivation of the dismissal

while as an Participant as intended in

paragraph (4), performed in accordance with regulatory provisions

laws.

BAB IV

HEALTH CARE DELIVERY MECHANISM

Article 11

(1) Health Service on the Benefit Coordination for

Advanced Inap health services at

outside Non-Specialistic cases.

(2) The health service specified

in paragraph (1) can be provided through the mechanism:

a. Referrals from FKTP that work closely with BPJS

Health;

b. Referrals from FKTP that do not cooperate with

BPJS Healthcare; or

c. Without referrals for medical emergency cases.

(3) The status of the Participant for health care as

is referred to in paragraph (2), listed as Participant

Additional Health Insurance.

(4) The health care provision through the mechanism

referral from FKTP that works closely with BPJS

Health as referred to in paragraph (2) letter a

as follows:

a. Participants due to medical indications of getting the service

Rawat Inap Advanced Level.

b. Participants showed a Shared Identity Card.

c. Participants attach a referral letter from FKTP that

works closely with BPJS Health.

d. Participants take care of the service administration as

Additional Health Insurance participants.

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e. Advanced hospitalization service warranty by

Additional Health Insurance Organizer

is granted during one treatment episode.

f. Additional Health Insurance organizers

provide ease in management

administration of services to Participants.

(5) Health services through the mechanism

referral from FKTP that does not work closely with BPJS

Health as referred to in paragraph (2) letter b

as follows:

a. Participants due to medical indications of getting the service

Rawat Inap Advanced Level.

b. Participants showed a Shared Identity Card.

c. Participants attach a referral letter from FKTP that

works closely with the Insurance Organizer

Additional Health.

d. Participants take care of the service administration as

Additional Health Insurance participants.

e. Advanced hospitalization service warranty by

Additional Health Insurance Organizer

is granted during one treatment episode.

f. Additional Health Insurance provides

ease in administration of service administration

to Participant.

(6) Health service via mechanism

with no referral to the medical emergency case

as referred to in paragraph (2) of the letter c as

below:

a. Participants with the medical gawatation case came

to FKRTL by showing the Identity Card

Together.

b. Participants get health care by

FKRTL.

c. Participants due to medical indications of getting the service

Rawat Inap Advanced Level.

d. Participants take care of the service administration as

Additional Health Insurance participants.

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(5) In case the Participant refuses to be transferred to FKRTL

in collaboration with BPJS Health, then since

the emergency conditions are resolved and the Participant in the condition

can be moved, BPJS Health does not provide

the tamer.

Article 13

As a precautionary measure for the occurrence of action

cheating in hosting warranty program

national health, BPJS Health and Organizing

Additional Health Insurance makes an effort

control in a way:

a. examine and research medical record Participants

Coordination of Benefits of RITL health services by

FKRTL;

b. examine the claim files and/or other supporters

submitted by FKRTL and/or Organizers

Additional Health Insurance; and/or

c. direct confirmation to the Benefit Coordinating Participant

associated grant Health service by FKRTL.

Section 14

In case there is a fraud (fraud) in

billing claim by Health Insurance Organizer

Additional, BPJS Health can do:

a. confirmation;

b. edits;

c. requesting overpaid; and/or

d. complete a pay shortfall.

over the claims bill of the Health Insurance Organizer

Additional.

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BAB V

BILLING MECHANISM AND CLAIM PAYMENT

Part Kesatu

General

Section 15

(1) For the RITL service provided to Participant,

Health Insurance Organizer Additional pay

claims as per the bill issued by FKRTL as appropriate

with the benefit of being the Insurance dependents

Additional Health.

(2) Additional Health Insurance Organizers

filed replacement reimbursions for RITL ' s services

Participation Coordination Benefits to BPJS Healthcare

in accordance with the INA CBG's tariff on each

FKRTL.

(3) Over payment of claims bill submitted by

Additional Health Insurance Organizer

as referred to in paragraph (2), BPJS Healthcare

provides reimbursed claims to Organizers

Insurance Additional health is at least as much as

INA CBG's Class C Hospital rates in its regionales.

(4) In terms of RITL claims bills from FKRTL lower

of INA CBG's Class C Hospital rates in its regionales,

BPJS Health paid the most reimbursed

much as the value of the claim was paid

Additional Health Insurance Organizer to

FKRTL.

(5) In terms of Participants being served in the lower class

of her right, the replacement is given according to the fare

class received by the Participant.

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Second Part

Terms of Document Claim

Article 16

(1) Additional Health Insurance Organizing

filed a claim collectively to BPJS

Health.

(2) The final limitation of claims filing collectively as

referred to in paragraph (1) is 6 (six) months since

the completion of care.

(3) Claims that the Insurance Organizer may submit

Additional Health to BPJS Health

as referred to in paragraph (1) is the claim

emergency and RITL.

(4) The claim submission as referred to in paragraph (1),

must satisfy the document's completeness as follows:

a. a copy of the Identity Card with the Coordinating Participant

Benefits;

b. Applicable Askom policies (policy date, coverage

coverage);

c. form and Document invoices claim from FKRTL; and

d. The FKRTL bill is equipped with the INA CBG's koding.

(5) The billing claim as referred to in paragraph (1)

is done through BOA.

Section 17

(1) In case there is a dispute in the implementation

The Coordination of Benefits between:

a. BPJS Health with Insurance Organizers

Additional Health;

b. Additional Health Insurance organizers with

Health Facility;

c. Participants with BPJS Health;

d. Participants with Health Insurance Organizer

Additional; or

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e. Participant with the Health Facility.

is resolved by means of deliberation by the parties

which is disputed.

(2) In case the dispute cannot be resolved

deliberations, the dispute is resolved in a mediation manner.

(3) Mediation as referred to in paragraph (2), first

times done by the Mutu Control Team and Cost Control

as well as the Medic Consideration Council which has been set up in

each region.

(4) In terms of mediation as referred to in paragraph (3)

not be reached and unterminated, next

mediation is conducted by the Settlement Alternative Institution

Disputes or other agencies as per the agreement of the

party.

(5) In case the dispute cannot be resolved through

the mediation process as referred to in paragraph (4),

the parties may resolve the dispute through

the court.

(6) The way of dispute resolution through mediation and through

the court referred to in paragraph (5)

is exercised under the provisions of the perinvite rule-

the invitation.

Section 18

Further terms on the technical filing claim,

billing claims and payment claims on coordination

benefits in the health guarantee program are set in

The Cooperation Agreement between BPJS Health with

Additional Health Insurance Organizer.

BAB VI

provisions CLOSING

Article 19

This Health Social Security Organizing Agency Regulation

entered into force on July 1, 2016.

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2016, No. 939 -19-

In order for everyone to know, ordered

The authoring of Guarantee Organizing Agency Regulations

The Social Health with its placement in the News

State of the Republic of Indonesia.

Set in Jakarta

on June 21, 2016

PRINCIPAL DIRECTOR

ORGANIZER

GOVERNING BODY

SOCIAL HEALTH CARE,

ttd

FACHMI IDRIS

Was promulded in Jakarta

on 28 June 2016

DIRECTOR GENERAL

REGULATION OF

MINISTRY OF LAW AND RIGHTS HUMAN RIGHTS

REPUBLIC OF INDONESIA,

ttd

WIDODO EKATJAHJANA

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