In the case of a planned admission, you would have first consulted a doctor who in turn would have advised you on the probable date of hospitalization. In such a case, you must apply for approval of the estimated hospital expenses directly by your TPA at least 4-5 days prior to the date of hospitalization.
In case you have not applied for pre-authorization sufficiently in advance or if the doctor treating you advises you to get hospitalized immediately after the consultation, our Corporate Help Desk (Phone: 022-24460649 / 24447543) will assist you through the pre-authorization procedure.
However, the Corporate Help Desk is only a facilitator and can in no way influence the decision on the approval. Your TPA may not grant approval due to any of the following reasons:
- If the ailment for which you are hospitalized is not covered in your policy.
- If the information contained in pre-authorization form is insufficient to approve the request, though most of the time the TPA will request the hospital if additional information is needed.
- If you have exhausted the sum assured for that year.
The pre-authorization procedure is detailed below:
Step 1: Establish contact with the Corporate Help Desk at the hospital.
Step 2: At the Corporate Help Desk, you need to present the original Health Insurance card issued to you by your TPA.
Step 3: Collect the pre-authorization forms pertaining to your TPA.
Step 4: Your pre-authorization form will have two sections-
- General details on the health insurance policy - to be filled in by you (the Corporate Desk will assist you in case you have any difficulty).
- The treatment recommended for you-to be filled in and duly signed by the doctor who is treating you (Do not attempt to fill this section, contact the Corporate Desk in case of any difficulty).
Step 5: Return the completed form to the Corporate Help Desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancy.
Step 6: Once the form is complete in all respects, the Corporate Help Desk will fax the form to the office of your TPA.
Step 7: The Corporate Help Desk will revert to you on the approval/denial status.
Step 8: At the time of admission, you shall be required to make a deposit payment of Rs.7500/- which shall be refunded post discharge ,subject to completion of all formalities.
You shall be required to
- Settle the difference, if any, if your bill exceeds the designated insurance amount.
- Pay for all non-medical expenses as your policy will not cover them.
- Check all the bills and prescriptions for any medicine that is billed but not administered to you.
- Note the total amount of the bill for your records for future purpose.
- Submit all the medical documents including the lab reports, claim forms, discharge summary and final bill to the hospital before being discharged.
The hospital, then, submits all necessary documents to TPA. TPA processes the bill on the basis of eligibility and actual cost. TPA makes the claim payment to the hospital and / or patient (as per the policy terms and actual cost). You shall, then, be refunded the deposit amount of Rs 7,500 with deduction if any.
What if the cost for treatment exceeds the approved sum?
Generally the TPA only approves a part of the expenses of the treatment and only after the hospital sends the final bill along with the discharge summary and other reports does it approve the entire amount.Sometimes the hospitals will request the TPA to increase the amount approved if needed during the treatment.
In an emergency hospitalization, the important thing is to get the patient treatment at the earliest. The Corporate Help Desk will take up your case on a fast track basis with your TPA and is likely to receive approvals within 6 hours during any working day.
Step 1: Show your health insurance card and fill in the pre-authorization form.
Step 2: The Corporate /TPA desk in the hospital will fast track the process for your cashless process but in case you cannot wait for the approval, you can pay the deposit if demanded by the hospital and start the treatment and reimburse the expense later on.
Step 3: Generally the time to taken to process an emergency case is 6 hours, but will depend upon the insurance co / TPA. You need to follow up with the TPA to know the status of the request.
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