No. The encounter code can only be generated by the enrollee or the VML contact center.

No, a visiting enrollee or an enrollee that has been referred does not need to provide an encounter code, they will be given a pre-authorization from the VML contact center. Encounter codes should only be provided by an enrollee visit to his/her registered primary provider.

No. An encounter code lasts for 24 hours.

No. You must not get an encounter code before you attend to any VML enrollee that has come to you facility under an emergency.

If an enrollee visit your facility without an encounter code:- i. Check if the enrollee is registered with your facility as his/her primary provider using the eligibility checker. If s(he) is, then ask him/her to generate an encounter code or contact the VML contact center. ii. If you do not find the enrollee details registered with you, kindly contact the VML contact center for verification and approval.

No. The eligibility checker list will be updated per minute and replaces the monthly patient panel previously sent by VML.

The tariffs for any service registered on the system would have previously agreed upon and approved by your facility management and VML. If there is any need to revise, reach out to our provider management unit for further discussions - "Provider Management" providermanagementhq@venusmedicare.com

Use the Eligibility checker to verify enrollee s registered with your facility.

Enrollee s benefit packages which contain covered services will be available on their profile page. You can also contact the VML contact center to verify.

The Check-in process, which replaces the signing of encounter form, is for the enrollee to consent that he/she actually received care at your facility on that day.

Contact the VML CC to assist.

Once you determine the service or medication is covered, contact our Provider management unit (providermanagementhq@venusmedicare.com) to agree on the tariff. Kindly, do this as soon as realized so the enrollee is not kept waiting?

Yes, there are different types of plans;  Instant Health  Smart Health  Classic Health  Super Health  Zenith Health

No, not at all. • He/ she can walk into his/her chosen hospital in the Provider network without notice and receive medical attention • You only need to generate an encounter code to access care at your registered hospital only • In an emergency, he/she may use any hospital on the network, using their ID card; the hospital only notifies the HMO [Venus Medicare] within 48-hours of setting off the medical care process. • Pre-Authorizations are required only for Secondary Services. Examples: Dental Care, Specialist Care, Pharmacy, etc

Yes, There are limits to the length of stay in the event of hospitalization  The maximum admission/length of hospital stay is 21 days per case  Duration for neonatal admissions vary based on the health plans

Yes, Venus Medicare LTD may cover the medical services rendered based on the enrollee’s benefit package, as long as the ailment is not on the exclusion list.

Yes, a GPcan refuse an enrollee a referral which he/she believes is needed if there is no medical indication for such referral. However, enrollees are entitled to have a second opinion.

No, a Service Provider cannot deny care to an Enrollee as long as the Enrollee is eligible to access care under Venus Medicare LTD.

Yes, both Generic and Branded drugs are covered.

Yes, pre-natal and post-natal care are covered under ALL the Venus Medicare plans.

Yes, Venus Medicare plans cover the provision of lenses with limits based on enrollee’s health plans

No, the provision of hearing aids, denture may ONLY be covered under customization.

No, this is a total exclusion under the Venus Medicare plans.

Yes, Venus Medicare LTD covers the management of chronic diseases except excluded conditions. However, FOR INDIVIDUAL PLANS, a pre-enrollment medical examination is required to compute premium for those with PRE-EXISTING CHRONIC CONDITIONS

Yes, there are; • There are limitations for example, Hormonal Drugs for Infertility Management (see exclusion list); • Expensive drugs above N5,000 per dose and medications used for management of chronic condition must be pre-authorized as they are classified under [Fee-for-service]; • To facilitate the settlement of claims, Venus Medicare LTD has developed in conjunction with care providers, a standard Drug Reimbursement Tariff [DRT] structure

Yes; • Voluntary counseling & testing are covered • Treatment of opportunistic infections • Anti-retroviral treatment facilitation at designated centers in Nigeria

The scheme is compulsory, not optional for corporate enrollees

The requirements for the enrollee to enjoy the scheme is for him/her to complete the Enrollee Questionnaire, supply names and passport photographs of self [and dependant(s), where applicable], so that relevant identification materials can be produced and forwarded to hospitals of choice and pay the premium of preferred plan. It takes not less than two (2) weeks to complete this process therefore all beneficiaries must comply promptly.

Yes; • The organization/ individual may introduce all providers [i.e. Doctors] that they were previously retaining for possible inclusion in the provider network; • Such hospitals if not already on Venus Medicare list of providers shall be inspected and registered, provided the hospitals are accredited by the NHIA, meet the minimum required standard and the management of the hospital is willing to join the scheme and abide by the rules guiding our operations. This is in the interest of all enrollees; • The hospital shall only be used eventually if not less than twenty [20] enrollees wish to use such a hospital, except there is no other hospital already listed in that town by Venus Medicare.

Yes • Every enrollee has the right to choose his/her hospitals from the provided hospital directory and respectively based on his/her plan as the hospitals are categorized based on the plan. • Principal enrollee may decide to use a different hospital from the spouse and children.

• Each enrollee and his dependants [maximum of spouse and four children] are entitled to unlimited medical facilities in the corporate plans. Where an extra dependant has been paid for by an enrollee, such benefits also accrue to that person. The individual plans have limits according to each plan; • The age limit for a child-dependant shall be eighteen (18) or maximum, twenty-one (21).

• For emergency/out of station conditions that occur within our service area, access the closest in-network hospital emergency facility anywhere in Nigeria, without the need to make any payment on production of your VML ID card, otherwise you may be denied treatment; • When out of our service area, access the closest hospital emergency facility. Enrollee and dependants are eligible for treatment in any unlisted hospital on production of member ID card, and contact VML-CC within 48hrs for notification and to obtain code where applicable. • However, some out-of-service-area medical facilities may require you to pay for your care at the time it is given. To arrange for reimbursement, send itemized bills and proof of payment within 90 days to the Venus Medicare claims. Refund code for such expenses should be obtain via our CC within 48hrs. The following would be requested during bill submission/reimbursement: presentation of receipts, Doctor’s report, bill breakdown and official refund request memo to Venus Medicare and follow by verification of such bills; • You will be responsible for out of area charges that exceed usual and customary charges; • If you are admitted to the hospital, you, a relation or next-of-kin must notify us within 48 hours. This is in the best interest of the enrollee. • Follow-up care is arranged through your GP.

 A medical emergency is a condition that manifests itself by acute symptoms of sufficient severity to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following: • Serious jeopardy to the person’s health, or with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child; • Serious impairment to the person’s bodily functions; • Serious dysfunction of one or more of the person’s body organs or parts.  Examples of emergency conditions include but are not limited to loss of consciousness, severe burns, severe pain, heavy bleeding, and possible heart attacks.

Yes The scheme covers the female enrollee and wives of male enrollees for antenatal care, child delivery up to four [4] life births and gynaecological treatment.

When specialist care is needed, your GP refers you to a secondary or tertiary centre where such facility is available.

Currently we do not have a provision for inter hospital transfer transportation. However, we cover for local evacuation to hospital (site to hospital).

No;  Deductions are not made on large bills against an employee’s name. However, enrollees should note that abuse of the managed health care system should not occur;  The mechanism of the scheme is that there is no financial limit within one contract year to encourage genuine visits to the hospital until you are certified fit health wise.

No except:  Enrollees or dependants will not be refused access to medical care because they frequently visit the hospital, except where an enrollee goes with a dependant that is not duly registered on the scheme;  Or, the enrollee asks for treatment of a condition that falls under our Exclusion list.

No;  Because the scheme works on the principle of pooling of risks, the excess money to treat individuals does not necessarily come from the premium contributed on a particular enrollee. It comes from other contributors to the scheme, which even spans beyond the population of any particular group;  Those who fall ill, use up the funds contributed by those who do not fall ill within the year, therefore there is no refund for non-utilization.

No. You are not allowed to substitute relations for children.

Report any dissatisfaction of medical services by your provider to your company representative or directly to Venus Medicare.

 Any enrollee reserves the right to change hospitals/ GPs at the end of the quarter or when he changes residence, provided the reasons put forward are tangible enough where it is for reasons other than change of residence;  Change can only become effective on the first day of each month when the new hospital/ GP chosen will have been adequately notified. Any request for a change or new entrant must be received by the 20th day of the month; otherwise action may be delayed by a month.

Capitation is the periodic upfront payment made to the provider on each registered enrollee with his hospital whether such enrollee(s) goes for treatment or not.

No;  The monthly Capitation which is paid to the provider whether the enrollee visits the hospital or not is for primary care ONLY and does not represent the cost of care receivable;  Not all persons paid for go for treatment every month; therefore, those who do not go for treatment bear the cost of those who go.

: No;  Capitation does not cover expensive drugs even when used for primary care conditions;  Some laboratory investigations, admissions, specialist treatment, surgeries etc are also not covered by Capitation.

No. Health Insurance is based on each individual life, hence substitution IS NOT ALLOWED. It is expected to be an annual contract.