Mediclaim Cashless Admission
The cashless access in TPA network of hospitals is merely a facility extended to you by the TPA under contract with your insurer.
How to get admitted in a network hospital / nursing home?
Pre-authorization is absolutely necessary without which the network provider will refuse cashless service. Please send the hospital admission request note from the attending physician stating the following to TPA via E-mail / Messenger.
Deposit policy paper / insurance card / Aadhar Card / Pan Card / Claim intimation.
In case of corporate clients, employee ID card or corporate name & employee number is mandatory.
Prior to admission, consultation, medication papers & investigation reports should be provided along with the request.
Arrange to submit completely filled request note from respective hospital. Planned hospitalization should be intimated to TPA at least 72 hours prior to admission. Emergency admission to be intimated within 24 hours after hospitalization.
Request note (Pre-Authorization Form) should be filled completely and duly signed by treating doctor & insured (along with undertaking) with hospital stamp. Mobile number of insured is mandatory.
The request has to be faxed or mailed by the hospital to insurance company. The insured can confirm receipt of request & further claim status by calling Call Centre of respective Insurance.
After confirmation of policy, insured & hospital coverage, the request will be registered by insurance company & a unique Claim Control Number (CCN) will be generated. This number will be exclusively used for all correspondence regarding that particular admission / hospitalization.
The claims will be reviewed by claim processor/s. The admissibility will be governed by the policy terms & conditions and ascertained on the basis of medication protocol as well as hospital tariff.
After review, if claim is permissible, insurance company will issue Authorization Letter (A/L) to the respective network hospital. All amount/s will be authorized as per hospital tariff, package or schedule of charges, mutually agreed upon with STAR / GIPSA / Private Insurance Companies, whichever is applicable as per policy. Insured should note that the policy may contain certain exclusions & / or restrictions which will be applied at the time of initial & final authorization. Non-medical expenses (NME) are not payable and will be deducted.
In case of any deficiency insurance company will raise query to hospital. The query should ideally be resolved within 24 hours. Once revert / reply is received, the claim will be re-processed based on merit (as mentioned in point no.9).
If coverage cannot be established the claim will be declined (denied) for cashless benefit. The denial of authorization for cashless access does not mean denial of treatment and does not in any way prevent you from seeking necessary medical attention or hospitalization. The insured/patient can submit documents for reconsideration in reimbursement along with claim form, in case claim is denied for cashless.
Prior to discharge please verify the Discharge Card & Final Bill. Patient/Insured should sign on the original copies as an acknowledgment.
Please carry home a copy of the signed bill, discharge summary and all your investigation reports. This is for your reference and will also be useful during your future healthcare needs.
The hospital will ask you to pay for all the Non-Medical Expenses / Disallowed in your bill. You have to make this payment before discharge. Copayment is a standard part of many health insurance plans. In final authorization, at a time there is a co-payment as per the policy terms and condition which is to be paid by the insured person. A co-payment is a fixed out-of-pocket amount paid by an insured for covered services.
Security Deposit has to be paid Rs. 5000 / 10000 for treatment till hospital gets payment from insurance company.
Security Deposit should be paid in Cash, if you pay by Debit Card / Credit Card then you will get refund by Cheque.
1Is the Insurance Card a Credit Card?
Please, note that the Insurance / TPA Card are only for the purpose of Identification of the Insured at the Network Hospital while availing Cash Less facility. It shall not be misunderstood with as a Credit Card. Cash Less facility is approved after due verification of Policy papers & Medical documents and is granted only when Authorization letter is issued to the Hospital. Mere acceptance of the Card at the Hospital does not entitle an Insured of an automatic Cash Less Access.
2When can a request for Cash less are rejected?
Cashless may be denied if found non-payable as per the Policy Terms, conditions & exclusions. Further, it is worth noting that Cashless facility is extended either, before or during the course of treatment. Decisions for claim payment are made on the basis of only few available documents. Given the nature of a particular case, the Cashless may also be rejected in the absence of relevant information required for arriving at clear decision. Also, the cashless request may be rejected in doubtful cases. Please, note that the denial of cashless access does not mean denial of treatment and does not in any way prevent the patient from seeking necessary medical attention or hospitalization. It also does not prevent the patient to submit his claim for Reimbursement.
3What is a Reimbursement Claim?
Reimbursement of Claim takes place when, after incurring the treatment expenditure from his pocket, the Insured claims payment under the Policy.
4What is the procedure for applying for Reimbursement Claim?
Intimation to regarding hospitalization is required to be made. Subsequently, the policyholder has to submit the relevant treatment papers & bills as prescribed by insurance company to claim the treatment expenses incurred, within 7 days from discharge from the Hospital.
5What are the Documents to be submitted under the Reimbursement Claim?
In support of the claim, please, enclose the following original documents (check with insurance company)
- Duly Filled in Claim Form.
- Discharge certificate/card from the Hospital.
- Indoor case paper
- Bills/ Receipts
- Cash Memos from the Hospitals (s) / Chemists (s), supported by proper prescriptions.
- Receipt and Pathological test reports supported by the note from the attending Medical Practitioner/ Surgeon recommending such Pathological tests.
- ECG, Chest X-ray, Sonography, Echo Cardiography, CT-Scan, MRI – all originals with receipt and reference letter.
- Certificate from treating Doctor regarding nature of disease.
- Copy of insurance card
- Copy of the Policy Schedule
- Cancelled cheque
- NEFT details
- Photo ID prof
- Others – If any
- Submit All Original Papers Related To Hospitalization And Xerox Copy Of Indoor Papers