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Protocols for Cashless
:
1) Patient should approach Insurance companies’ Network hospital
based on recommendation of physician or in emergency.
2) Show Cashless Card to the Hospital Help desk/ Front Desk person.
In case of an emergency admit the patient in the Hospital, obtain a
pre-authorization form, get it file, take the sign of the doctor
under which treatment took in case of emergency, and submit it to
the Hospital, which will fax the Pre Authorization to TPA along with
necessary investigation reports. After investigation, TPA will fax
the approved cashless authorization letter to the hospital.
In case of planned hospitalization, the insured must go to the
hospital at least 72 hours before admission to hospital and provide
them the following details: cashless Card, Letter from the
consulting Doctor stating the Diagnosis, Date of Admission. Inform
TPA at least 2 days before admission about the hospitalization, plan
of treatment, cost estimates etc. At the time of admission, present
the authorization letter and photo Health card to the hospital.
The cashless may reject - if the current ailment does not cover
under the purview of the policy, if the information sent by you to
TPA is insufficient and if the request for pre authorization does
not sent in time.
At the time of discharge – pay for all those expenses that are not
reimbursable under the policy, verify the bills and sign on all
bills and keep a Xerox of all bills and reports in your record.
In case cashless is not authorized then pay all the bills which will
be reimbursed
CLAIMS
REIMBURSEMENT PROCESS
As soon as there is need of hospitalization whether in emergency or
a planned one intimate the TPA on the helpline and submit the
following details- Name Of The Insured, Nature of Sickness, Policy
Number, Date And Time Of Accident Or Onset Of Disease. At the time
of discharge settle the hospital bills in full and collect all the
original bills, documents, reports and discharge summary. Then lodge
your claim with TPA for processing and reimbursement by filling in
the claim form and attaching required documents.
DOCUMENTS
NEED TO SUBMIT
Claim Notification: - Must be sent within 7 days from date of
admission. Can be letter/f ax/ email. But essential for processing
claims. Claim form (complete in all respects) should then be
submitted within 7 days from the date of discharge along with the
following documents. Please inform us if there is going to be any
delay in submission of the same. Claims received after 30 days from
the date of discharge cannot be reimbursed.
Discharge summary:-
This has to be original & must have the following details:
1) Name & Age of patient
2) Date of admission
3) Symptoms/appearance of the patient at the time of admission
4) Initial diagnosis
5) Tests for analysis
6) Final diagnosis
7) Course of treatment in the hospital
8) Discharge advice
Detailed
bill –
This should contain the breakup of all the items/medicines/tests.
Consolidated bills without item wise billing are not acceptable.
Incase of surgeons/consultants bills, kindly insist on a stamped,
preferably numbered receipt with doctor’s registration number
Prescriptions - For all tests / medicines. If the same appears in
the discharge summary, will do. However, item wise should match.
Reports - Reports for all tests advised. No need for x-ray/CT scan/MRI
films. But reports essential.
Payment receipt - Must necessarily be a proper receipt with revenue
stamp affixed and signed by the hospital authorities. This cannot be
combined with any other documents like the discharge summary/bills
etc.
Non-medical expenses like admission/ registration charges, attendant
charges, and diet charges, telephone/ television charges etc do not
reimburse. Any miscellaneous/ services/ administrative charges that
do not pertain to the actual medical treatment will also not be
reimbursed.
The TPA can still ask for further details depending on the
complications of this case but this list if complied will solve 90%
of the claimant’s problem.
Our Help Line Numbers: 9830 200 799
Some Do’s
and Don’ts
1) ALWAYS carry your cashless card while going to the Hospital
2) Maintain All Bills relating to Hospitalization, including Pre and
Post in original.
Remember to take the bills from your Family / Consulting Doctor
3) Never disclose the amount of Coverage to the Hospital as they
might increase the bill which will affect you as well.
4) Do not go for very expensive treatment or expensive hospitals if
not necessary, as the limit might get exhausted in case there are
more claims in any particular year
5) Ask the hospital authorities about the approximate cost of
treatment beforehand
6) Before hospitalization, get it clarified whether the particular
disease is covered under your policy terms and conditions or not
7) Do not panic in case of an emergency. Procedures and rules have
to be followed and paper work needs to be completed for Cashless.
8) Request the hospital authorities to send the necessary papers to
the TPA at the earliest, without which, claim cannot be processed &
Cashless cannot be granted |
