Mediclaim Insurance is a contract between insured (patient) and insurance company. Insurance company operates through TPA (Third part Administrator) MOU done by TPA with hospitals offering cashless services to mediclaim patients.
Hospital is only a facilitator between TPA & patient. Hospital is not responsible for approvals, objections, delays, deductions & denials for mediclaim cases. The hospital supports the patient in getting cashless facilities.
As a rule, if someone is coming for a planned admission, they should come with an authorization letter. For TPA for all emergency admission, hospital will assist in the cashless procedure.
Approval is given by TPA as per each specific policy terms and conditions.
TPA takes into consideration :
1 PPN Packages (Private Provider Network)
Insurance companies have fixed charges for certain treatments and is applicable to various hospitals who are part of PPN network.
Yes. On admission deposit is collected from patient as per hospital Schedule of Charges.
If cashless approval is not received on before of surgery, amount due for OT clearance is to be deposited mandatorily. Deposit shall be adjusted against non admissible and any other deduction by the TPA
Yes. Hospital will update you about the status of the claim right from first approval, query clarification and final approval. Detailed information shall be available from TPA front desk.
Hospital does not encourage availment of stay which patient is not entitled to as per his policy.
No. Only 1 policy shall be considered for cashless by the hospital. The patient has to go for reimbursement for utilization of the2nd policy.
Only photocopy of the documents shall be provided to the patient as Originals are required by the TPA for processing the claim.
Hospital has no role to play in expediting the approval as powers to approve lie with TPA and Insurance company. It’s the responsibility of the patient to contact the TPA, if the authorization is not received on time.
The TPA front desk at hospital is open from 9.30 A.M to 19.00 P.M everyday. On weekends some of the TPA’s are not working and this might result in delay. TPA’s are not open on public holidays too.
Process will be done on next working day. Till process it will be considered as regular paying patient only.