Insurance Process FAQs for Hospital Admissions

FAQs

In this article we will look at:

What is a TPA?

Third Party Administration (TPA) is a service for the mediclaim policyholders. It comprises cashless facilities for all the hospitalizations that fall under the scope of their mediclaim policy.


What are the benefits of TPA for a policyholder? 

TPA has manifold benefits:

  • The policyholder can choose any hospital from the respective TPA’s empanelled network, for availing treatment
  • The policyholder can easily check whether or not their treatment is covered under the policy. If covered, then they can seek cashless facility at any of the respective TPA’s network of hospitals.
  • In cases of emergency hospitalisation, admission can be sought by merely showing the policyholder’s Photo ID, at any of the TPA’s network of hospitals. TPA service makes the whole experience hassle-free by removing the need to pay cash. Also, TPAs have ambulance referral, surgeon's referral and specialist's referral.

What are the facilities offered by a TPA? 

TPA offers the following facilities:

  • Cashless service at network hospitals, up to limit authorised by mediclaim / hospitalization insurance
  • 24x7 assistance to all policyholders through a toll-free number
  • Online assistance during hospitalization and filing of a claim
  • Assistance in providing ambulance services during an emergency
  • Enrollment Card against your policy that would give you access to TPA services
  • Processing of claims and reimbursements for non-network hospitals
  • Other services as defined by the employer or insurer

What do you mean by network/non-network hospitalisation?

Hospitals that have an agreement with a TPA for providing cashless treatment are referred to as 'Network Hospitals'.
Non-network hospitals are those that are not associated with the TPA. At these hospitals, policyholders will have to pay for the treatment and file claim as per the usual procedure.


What is cashless access/cashless facility?

Cashless access means that you can walk into any hospital within the TPA network and seek treatment without having to pay bills or filing claims separately. In case of admission to a hospital outside the TPA network, your expenses will be reimbursed on receipt of completed claim documents.


How do I avail the cashless facility?

Cashless facility is only available at the network hospitals. In case the patient wants to be referred to a network hospital, the TPA needs to obtain the following documents from the patient before issuing a pre-admission authorization for the cashless facility:

  • Request for Admission Form duly filled in and signed by your doctor. In most of hospital this is taken care by admission desk.
  • Patient’s ID proof and an address proof is mandatory (Voter’s Card/Ration Card/Driving Licence/Passport/Adhaar Card)
  • Health Insurance e-card or TPA issued e-card
  • Investigation reports related to relevant treatment
  • Treatment record related to current hospitalisation
  • For Corporate patients, Employee Card and an ID proof
  • Pre-authorization form, along with the above-mentioned papers should be submitted at the Admission/ Insurance Desk within 24 hours of admission.


Which documents should one obtain before discharge from a hospital when the cashless facility is not availed?

You should obtain the following documents before discharge, if the cashless facility is not availed:

  • Original prescription (on official letterhead) from the doctor, complete with hospitalisation advice and details of the symptoms and diagnosis
  • Hospitalisation form in the given format
  • Details of the previous policies, if they are not already available with TPA, except in case of accidents

If the case information is incomplete in the hospitalization form or if the history of the disease unconfirmed, then a pre-admission authorization cannot be issued for the cashless facility. In such cases, if the patient is admitted to a network hospital then the treatment will be same as in the case of a non-network hospital. The doctor must mention in the history sheet: history of the disease and relation to pre-existing diseases like hypertension, diabetes etc. (if any)


What documents are needed for processing claims if the treatment has been done in a non-network hospital or in a network hospital where cashless facility is not available?

Following documents are required for processing the claims on the reimbursement basis:

  • The claim form, properly filled and signed by the claimant
  • Discharge certificate from the hospital
  • All documents pertaining to the illness starting from the date it was first detected
  • Bills, receipts
  • Cash memos from hospital supported by proper prescription
  • Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics. Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt
  • Bill, receipt and diagnosis certificate from the attending doctor/consultant/specialist/anesthetist
  • Certificate from the attending medical practitioner/surgeon stating that the patient is fully cured
  • Details of previous policies: if the details are not already with the TPA, except in the case of accidents

Which documents should I carry with me while going to hospital at the time for admission?

Following is the list of documents that must be carried for admission:

  • Request for Admission Form duly filled in and signed by your doctor. In most of the hospitals, this is taken care by admission desk.
  • Patient’s ID proof and an address proof is mandatory (Voter’s Card/Ration Card/Driving Licence/Passport/Adhaar Card)
  • Health Insurance e-card or TPA issued e-card
  • Record of treatment prior to this hospitalisation
  • Doctor’s prescription/discharge summary of the previous admission, if any
  • Investigation reports related to relevant treatment
  • Treatment record related to current hospitalisation
  • OPD prescription
  • For Corporate patients, Employee Card and an ID proof
  • Pre-authorization form, along with the above-mentioned papers should be submitted at the Admission/ Insurance Desk within 24 hours of admission.


When will my claim be reimbursed?

The claim will be reimbursed after receipt of complete documentation from the claimant.


Can I get cashless facility/reimbursement in the case of pre-existing diseases? 

Pre-existing diseases are excluded in mediclaim policy. TPA’s doctor panel will verify/check the inception of disease based on your medical records and in case the disease has an origin before the inception of the policy, then your claim will be deemed “not payable”, as per the policy.


Can I get cashless facility/reimbursement within 30 days of policy commencement?

Mediclaim policies have a waiting period of 30 days. Only accidents if occurred during the first 30 days of the policy are covered. Any other disease is not payable.

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