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Cashless Hospitalization Claim Process

The flow chart outlines the process for cashless and reimbursement hospitalization through a third party administrator (TPA). For planned hospitalization, the insured must complete pre-authorization formalities with the hospital 48 hours prior to admission. The hospital then sends documents to the TPA for approval within 3 hours. For emergency hospitalization, pre-authorization must be completed within 24 hours of admission. If approved, the TPA issues an authorization letter, but if declined a denial letter is sent. For reimbursement claims, the insured submits documents to the TPA within 30 days, and payment is made within 15 days if approved or a denial letter is sent if declined.

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346 views2 pages

Cashless Hospitalization Claim Process

The flow chart outlines the process for cashless and reimbursement hospitalization through a third party administrator (TPA). For planned hospitalization, the insured must complete pre-authorization formalities with the hospital 48 hours prior to admission. The hospital then sends documents to the TPA for approval within 3 hours. For emergency hospitalization, pre-authorization must be completed within 24 hours of admission. If approved, the TPA issues an authorization letter, but if declined a denial letter is sent. For reimbursement claims, the insured submits documents to the TPA within 30 days, and payment is made within 15 days if approved or a denial letter is sent if declined.

Uploaded by

anjna
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Cashless Hospitalization Process
  • Reimbursement Process

Flow Chart For Cashless Hospitalization

Planned Emergency
Hospitalization Hospitalization

Approach hospital 48 hrs. prior to


admission , produce TPA card and
Admission in Hospital
complete pre-authorization
formalities

Pre-Authorization formalities to be
Fax Pre-Authorization letter to
completed within 24 hrs and sent to TPA
TPA for Approval
for Approval

If all the documents are in order, If all the documents are in order, TPA
TPA will issue authorization letter will issue authorization letter to hospital
to hospital within 3 hours within 3 hours

If the case is Declined, Denial If the case is Declined, Denial Letter will
Letter will be issued to be
hospital (denial of issued (denial
cashless does not mean denial of of cashless does not mean denial of
treatment or claim) treatment or claim)

In case additional information is In case additional information is


required, TPA will inform the required, TPA will inform the Hospital /
Hospital / Employee Employee
Flow Chart For Reimbursement Process

1 2 3 4
Submit all Original
Collects all Original
Hospital
documents,
Insured visit non documents along
Takes Discharge , receipts and
network hospital with filled claim
pays for treatment investigation
for treatment form within 30
reports from
days from date of
Hospital
discharge to TPA

5 6 7 8
TPA Helpdesk Incase additional
acknowledges information is If Claim Payable,
receipt of claim required, TPA will payment will be If Claim Declined,
documents via inform the made to Corporate Denial mail will be
email and Employee via via NEFT within 15 sent.
commences claim email with 3 working days
process reminders

Flow Chart For Cashless Hospitalization Planned Hospitalization Emergency Hospi
Flow Chart For Reimbursement Process 1 2 3 4 Insured visit non network hospital for treatment Takes Dis

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