Insurance
General Health Insurance
Cashless claims in our hospital (PSG Hospitals)
TPA(Names)
• MD India healthcare service pvt ltd
• Good Health Plan Ltd
• Medi assist India pvt ltd
• TTK Health care services pvt ltd
• Bajaj allianz general insurance company ltd
Procedure For Cashless Claims
A. Admission Procedures
B. Pre - authorization
C. Discharge Procedures
A. Admission Procedures
• To check the availability for cashless through ID Cards
• The beneficiaries (patient) will be identified by the provider (hospital) on the basis of an ID card issued from TPA to all the beneficiaries.
• The ID card shall have photograph and signature or thumb impression of the Patient.
• Whenever there is a need for hospitalization the policyholder should bring their ID card and policy copy.
Insurance clerk will verify following details through ID card & policy copy
• TPA Name
• Corporate name
• Patients name and spelling
• Card validity from and To
• Age verification
• Photograph verification
• Pre existing coverage
• Sum-insured
To explain clearly about the terms & conditions for availing cashless facility to the patient.
B.Pre-Authorization
The terms & conditions for providing cashless facilities to the patient.
• When a Doctor planned for surgery, the insurance clerk should fill the pre-authorization form and fax it to TPA. This should be done at least 4 days prior to the expected date of admission.
• In case of emergency hospitalization, the form is to be filled by the concern Doctor and the insurance clerk should complete the pre-authorization form and fax it with in 24 hours of admission. In case if it is any delay in sending the form to TPA, it should be properly communicated by insurance clerk to TPA through phone.
• The Pre authorization certificate which was sent by the insurance company will have the following details like amount guaranteed, class of admission, eligibility of beneficiary or sub limits for rooms & board, surgical fees etc. As per the benefit plan of the insured, the insurance company should strictly follow the above rules.
• The guarantee of payment is given only for the necessary treatment cost of the ailment covered and mentioned in the request for hospitalization. Non medical expenses must be collected directly from the patient. Any investigation or treatment carried out at the request of the patient apart from the authorization those treatment charges are collected from the patient.
• When the cost of treatment exceeds the authorized limit at the time of discharge the insurance clerk should send the enhancement to the TPA. If it is approved, only non- medical expenses are collect from the patient. If the TPA sends no more enhancements, we should collect balance amount from the patient.
C.Discharge Procedures
• To check the authorized limit of the patient & certain exclusions mentioned i n the pre-authorization.
• Hospital amount when exceeding the authorized limit, to send enhancement for the Exceeded amount.
• The final authorization for the enhancement when received, to discharge the Patient once the payment towards the exclusions is collected
• If the enhancement amount is unauthorized, it should be collected from the patient