A Third Party Administrator (TPA) is an important link between insurance companies, Policy holders & healthcare providers (hospitals). TPA’s role is to provide administrative support to the insurance companies for servicing their insurance policies. However, it is important to understand the role of a hospital in cashless hospitalization.
The hospital is only a facilitator and has no authority to approve/disapprove any request for cashless hospitalization. Protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalization will need to be adhered to strictly. You are the beneficiary of the insurance company and we request you to spare some time to understand the processing of insurance claims.
Insurance companies have appointed TPA’s (Third Party Administrators) to give you the facility of cashless hospitalization. The claim is processed by the hospital subject to approval by your TPA. “Sri Ramakrishna Hospital Claims Department” is only helping you to get your claim processed by TPA. In the event of the cashless authorization request being rejected by TPA, the patient has to pay the bill to the hospital, and try to reimburse the expenses subsequently from the Insurance company or TPA
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 an approval of the estimated hospital expenses with your TPA at the date of hospitalization. Our SRH Claims Help Desk (Claims Department) will assist you with the pre-authorization procedure. However, you will need to bear in mind that we only a facilitator and can in no way influence the decision on the approval. Approval/denial of cashless facility is the decision of the TPA, depending on your policy terms & conditions.
The Pre-Authorization procedure is detailed below:
- Establish contact with the Hospital Claims Desk (Department) . OUR CLAIMS DEPARTMENT STAFF WILL GET IN TOUCH WITH YOU AS SOON AS YOU LANDED IN THE HOSPITAL.
- At Our Hospital Claims Department, you need to present the original health insurance card issued to you by your TPA along with photocopy of your insurance policy. Also, produce a photocopy of ID proof issued by Govt. Authorities (PAN card/ driving license/ voter ID card etc). Alone with this please produce your photocopy of employee ID card if it is a TPA group insurance policy/ corporate policy.
- Collect the pre-authorization from pertaining to your TPA.
- Your pre-authorization will have two sections – – General details on the health insurance policy – to be filled in by you (we will assist you in case you have any difficulty). – Details pertaining to the treatment recommended for you-needs to be filled in and duly signed by the doctor who is treating you (do not attempt to fill this section).
- Return the completed form to Our Hospital Claims Desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancy.
- Once the form is complete in all respects, the Claims Help Desk will fax/mail the form to the office of your TPA.
- Our Claims Help Desk will revert to you on the approval status. TPA usually approves a part of the total estimate called “Initial Sanction”. Cashless hospitalization is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval, you will need to bear the entire expenditure incurred on the treatment.
For cashless treatment, it is mandatory for the hospital to have an approval from your TPA. In case of delay in receiving the approval, or when you cannot wait for receiving the approval owing to medical urgency, you can undertake the treatment by paying the necessary cash deposit. In case of emergency hospitalization, the Claims Help Desk will take up your case on a fast track basis with your TPA, and is likely to receive approvals within 3-4 hours during any working day. If you receive an approval from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit by cheque, within 2-3 working days after discharge.
In case your hospitalization expenses exceed the pre-approved amount, you can approach our Claims Help Desk to apply for an enhancement of the pre-approved amount. We will apply for an enhancement on your behalf with the TPA and provide the necessary documentation. In case you have not exhausted your medical insurance limit, it is most likely that your TPA will approve the application for the enhancement – either for the requested enhanced amount or up to your insured limit after deducting the value already utilized by you during the year – whichever is less. If the TPA turns down the request for enhancement, you will need to pay the amount incurred in excess of your approved amount directly to the hospital before the discharge.
Any additional complication/ treatment over the estimate will be sent to the TPA for approval. In case of denials, the same should be paid at the time of discharge, and can be claimed for reimbursement from the TPA. For complete details on the medical expenses that are covered, and those that are not covered, you need to go through your health insurance policy. However, in general, the expenses listed below are not reimbursable under cashless hospitalisation.
- Registration / Admission Fee
- Telephone Charges
- Visitors/Attenders Charges
- Ambulance Charges
- Charges for diet, which is not part of the administered treatment
- Document charges
- Non-medical expenses
- Service charges, etc.,
These needs to be settled by you directly with the hospital at the time of discharge.