How Health Claims will Settled for Cashless & Reimbursement

Here is the process involved in How Health Insurance claims will settle, Just check the process and know how and when cashless and reimbursement claims will settle at priority…

Health polices are issued by General Insurance Companies and stand alone Health Insurance Companies. Each Company has different health policies.

Unlike other claims, Health claims are different and need to be settled as early as possible because in health claims patient’s health condition also depends on it. Most of the health claims settled through TPA (Third Party Administrator). In some Companies claims will be settled by their own claims handling team.

What is TPA

TPA means Third Party Administrator. It is having a license from IRDA (Insurance Regulated Development Authority) to process the claims. TPA acts as an Intermediary between Insurance Company and customer for claim processing. In TPA, experts team who are all qualified or trained persons will handle health claims.

Process for Settling Health Claims

Generally, health claims are settled in two ways:

  1. Cashless claims
  2. Reimbursement claims

Cashless Claims

Cashless Health claims mainly settled in Network Hospitals. Network Hospital is nothing but Hospital which is already tied up with Insurance Company or TPA

TPA or Insurance Company will negotiate with the Hospital regarding each and every treatment and its cost. After agreement of terms Hospital will enter into Network list of TPA or Insurance company

While admitting in hospital patient has to carry their Mediclaim card which is provided by insurance company along with ID proof.

In each hospital Separate health desk will be there for handling cashless claims and all the proofs has to be submitted there. Then hospital’s cashless team will send a mail of patient’s health records, course of treatment or operation to be performed and Mediclaim ID card and identity proof to TPA or Insurance company for cashless approval.

Cashless approval will be given by TPA or Insurance company after observing patient’s eligibility based on the policy he has taken, seniority in Mediclaim policy for said treatment.

Once cashless approval received from TPA or Insurance company, treatment to the patient will start by hospital team.

On the day of discharge same cashless team will send a mail to TPA or Insurance company regarding entire process of treatment and detailed bill to TPA or Insurance Company. Once they have received approval from TPA or Insurance company for the full amount they will discharge the patient.

If the TPA or Insurance company approved amount is less than Hospital bill the balance has to be paid by the patient. This may be because TPA or Insurance company agreement with the hospital for said treatment will be less than the bill produced by the hospital. In another case the patient’s sum insured is less than the hospital bill.

Reimbursement Claims

In this process initially patient has to pay the full bill to hospital later he has to get reimburse from the insurance company. Patient has to submit it all records required by Insurance company or TPA along with a claim form.

Main documents required are

  1. Discharge summary
  2. Hospital main bill
  3. Hospital bifurcation bill
  4. Prescription from doctor for investigation
  5. Investigation reports like scanning, Blood test, Urine tests, x-rays etc
  6. Investigation report bills
  7. Pharmacy bills

In claim form there will be two sections. One section should be filled by patient and other section should be filled by hospital authority along the signed seal.

Along with reports and documents, patient needs to submit Bank details copy, Identity proof Mediclaim ID card and Policy copy. After getting all required documents patient has to submit original forms in the insurance company and should keep a copy of those records.

Once claim will be intimated, you can track the claim status through TPS website using patient’s TPA ID number. Actually, reimbursement process is a tiresome process and also insured has to wait for a long time to get the reimbursement.

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