Mediclaim Policy for JSLPS

 

Cashless and Reimbursement Claim Process

—  HOW TO CLAIM HEALTH INSURANCE:-

 

—  Health insurance claim is a request that a health insurance policyholder submits to the Insurance Company in order to obtain the services that are covered in their health insurance policy. A health insurance policyholder can either get reimbursed or can opt for a direct claim settlement option (also known as cashless treatment) for the availed medical services. In this way, one can either submit the claim form or request the health insurance provider for cashless services. 

Types of Health Insurance Claim:-

—  Providing healthcare service when needed is the true utility of a health insurance plan. To ensure timely and easy settlement of all the medical expenses, one needs to initiate the health insurance claim process. There are two ways to claim a health insurance policy:

—  Cashless Claims :

—  In this type of health insurance claim, the insurer settles all the hospitalization bills with the hospital directly. However, an insured needs to be hospitalized only at a network hospital to get the benefit of cashless hospitalization.

—  Reimbursement Claims :

In this type of claim process, the policyholder pays for the hospitalization expenses upfront and requests for reimbursement by the insurance provider later. One can get reimbursement facility at both network and non-network hospitals in this case.

Health claims process 

Cashless 

  Emergency Hospitalization

v  Has to contact the hospital (only network hospital) with the health card. If a health card is not available at the moment patient- the party has to communicate to the hospital that the patient is a JSLPS Employee or Member & provide them the Employee ID. Later on, the health card has to be provided to the hospital. ( Always carry a Copy of Health Card, Pan  & Adhar )

v  Submit all the documents to the insurance/TPA help desk of the hospital.

v  Hospital will send the documents to TPA for cashless processing.

v    After processing the request for a cashless facility TPA will send the letter (query/approval/Rejection) to the hospital and SMS will be forwarded to the insured. If there is any additional document requirement, that should be submitted to the hospital. The processing of the claim can be in 3 mode-1. Approval 2. ADR ( Additional document requirement ) 3. Rejection ( If a particular disease doesn’t come under mediclaim coverage. )

v  First an initial approval is given based on the treatment documents received from the hospital. once the discharge is finalized & the final bill and discharge summary are forwarded to the TPA final approval are given.

Reimbursement 

Wherever the member has already borne the hospitalization expenses and wants to reimburse the same the following documents have to be submitted at the TPA in order to process the reimbursement claim.

The documents required are as follows

v  CLAIM FORM – Part A to be duly filled and signed mentioning the claim amount. Part B Claim form should be filled by the hospital authority with sign & hospital seal.

v  Photo copy of TPA Health Card, PAN, ADHAR & JSLPS ID CARD.

v  Discharge Summary/certificate OR Day Care certificate.

v  Hospital Final Bill with a detailed breakup.

v  Hospital Payment Receipts in the proper numbered format against payment of the hospital.

v  Doctor’s prescription advising for admission in the hospital / Nursing home.

v  During reimbursement intimation has to given – planned case : 3 days prior to admission, emergency with in 72 hours of admission.

Reimbursement 

 Wherever the member has already borne the hospitalization expenses and wants to reimburse the same the following documents have to be submitted at the TPA in order to process the reimbursement claim. 

The documents required are as follows

v  Prescription for Medicines/Investigations done.

v  Medicine Bills/Cash Memos mentioning Patient Name/Doctor Name, Batch No. & Expiry date.

v  Investigation/X-Ray Reports & Plates.

v  Hospital Final Bill with detail breakup.

v  Invoice & Sticker of implants (vis- Stent/Pace Maker/IOL/ PHS mesh etc).

v  Detail breakup of package charges.

v   In Road Traffic Accident case Self Declaration in details, Attested copy of FIR/MLC

v  In death case- death certificate issued by the hospital/nursing home and Corporation.

All documents submitted in reimbursement should be original.

Note: the above-mentioned checklist is not exhaustive. the requirement may differ on a case to case basis.

Claim Intimation & Submission

—  Claim Intimation of any hospitalization in network / non-network hospitals needs to be given in writing to the concerned insurance company or TPA with the following information:-

—  Patient Name

—  TPA Membership ID

—  Date of Admission

—  Expected Date of Discharge

—  Name & Address of the Hospital

—  Name of the Treating Doctor

—  Name of the Disease

—  Contact no. of insured

—  Estimated expenses in Approx.

—  The same is applicable for both cashless & reimbursement claims.

—  For Planned Cashless Hospitalization the intimation should be given to Insurance Co / TPA 72 hours before admission.

—  For Emergency Cashless Hospitalization intimation should be given within 24 hours of admission.

—  For reimbursement claims/admission in non-network hospitalization should be given within 72 hours of admission.

—  All the reimbursement Claim file should be submitted at TPA end within 30 days of discharge date.

Pre- Post Hospitalization Expenses 

•       As per normal policy condition, Pre-Hospitalization expenses are expenses incurred 30 days prior to admission & Post –Hospitalization expenses are expenses incurred 60 days post-discharge. These expenses are payable under a normal policy conditions.

•       You Cannot avail of the cashless facility for these expenses. You need to claim through reimbursement mode.

•       Expenses like Medicines, Doctor Consultations & Investigation can be claimed under  Pre  & Post Hospitalization expenses.

Key Points for Hospitalization Claim documents submission 

•       24 Hours Hospitalization is a must, In case of one-day hospitalization ( Other than Day Care Procedure ) exact date & time of admission/discharge is mandatory.

•       All documents should be in original ( Duplicate / Xerox not acceptable )

•       Doctor A prescription with advice for admission. Commencement of disease & Past history should be mentioned in Doctor Prescription or in Discharge Summary.

•       All supportive investigation reports, films & plates.

•       Cost wise Break up of Medicines Bill with batch no. & expiry date ( Supported by Doctor Prescription )

•       Detailed Hospital bill with head wise breaks up along with Hospital Seal & Sign.

•       Separate Money Receipt against Payment of Hospital Bill ( Pre-printed / Computer Generated ), Doctor Fees / Diagnostic, or Pathology Charges.

•       Discharge Summary / Card / Certificate.

•       Separate invoice & Sticker ( In case of Implant ).

•       Break up of OT Medicines / Consumables / Bulk medicines / Bed Charges. ( If any )

•       Original prescription / Doctor notes of previous treatment for the presenting complaint.

•       Copy of Insurance / TPA Card & ID Proof ( Adhar Card & Pan Card ).

•       Bank Details of Primary Member ( Employee ) along with Cancel cheque.

For Accidental Cases ( RTA / Injury at home or somewhere)

•       Attested Copy of MLC ( Medical-Legal Certificate ) or FIR

    ( First information Report ).

•       Self declaration with details of injury ( Date, Time & Place is mandatory )

•       Treating Doctors have to certify Alcoholic History.

Exclusion 

•       Dental Treatment, Cosmetic  & Plastic Surgery  (Unless requires Accidental Hospitalization)

•       Diagnostic Test (Unless Directly Connected to Illness)

•       HIV Aids, Congenital Disease, Circumcision, Psychiatric & Mental  Disorders, Drug-Tobacco or Alcohol Disease, Naturopathy, Vaccination, Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of spectacles, and contact lenses, hearing aids including cochlear implants, durable medical equipment, Hospitalization due to suicide, Genetic disorder.

•       War related disease or contribute by Nuclear weapons/material,  Family Planning, Ligation