are the four General Insurance Companies in INDIA functioning independently. They have formed an association known as General Insurers Public Sector Association of India (GIPSA) for offering cashless services to the needy patients by the Third Party Administration (TPA) Firms.
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 are only a facilitator and can in no way influence the decision of the approval. Approval/denial of cashless facility is the decision of the TPA, which depends on your policy terms & conditions.
The Pre-Authorization procedure is detailed below:
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 hospitalization.
These needs to be settled by you directly with the hospital at the time of discharge.
Mr. C.R.Ramkumar – Manager (Claims & Accounts)
Phone : 0422-45 00 000
Fax : 0422-22 40 521
Mobile : 73737 77699
Email : email@example.com, firstname.lastname@example.org, email@example.com
SRI RAMAKRISHNA HOSPITAL
395, Sarojini Naidu Road, New Siddhapudur,Coimbatore – 641 044.