Philippines Itemized OHI Claim Checklist
This form has two purposes to assist you in with your claims:
- You should use this form (pages 1 and 2) when your other health insurance (OHI) plan (such as PhilHealth,etc.) does not, cannot, or will not do a proper explanation of benefits (EOB) or other document showing what was paid and what was not paid. An OHI's EOB is still the preferred document to mail to WPS along with your claim. You are still required to file with your OHI first within the parameters of how your OHI plan operates.
- Page 1 of this form serves as an itemized bill or receipt of services received/paid for, when a provider cannot or will not produce an itemized bill, receipt or statement of services rendered. The form must be complete and signed by the provider.
TRICARE Philippine Demonstration
Use this form to requst a waiver to visit a non-approved demonstration provider. International SOS will review beneficiary submitted waivers and notify the beneficiary of the decision.
Beneficiary Waiver Appeal
Use this form to formally request a review if the waiver is denied. Appeals are forwarded to the TRICARE Area Office (TAO)-Pacific for subsequent consideration.
Send all Beneficiary Waiver Request Forms and Beneficiary Waiver Appeal Forms to Global 24 Network Services by mail or fax:
Global 24 Network Services
P.O. Box #13892
Emerald Avenue, Ortigas Center Post Office
Pasig City, Philippines 1605