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Pre-Authorisation Guide


To ensure prompt approval of cashless requests and settlement

 

Steps to be followed

 

  • Submit the pre-authorization request on the latest form circulated by the TPA. Earlier forms do not contain fields now mandated by the IRDA. Latest Pre-authorisation Request Form.
  • Ensure that all the columns in the pre-authorization request form are duly completed LEGIBLY
  • Avoid use of abbreviations while recording ailments/ procedures – this would take more time for the approver to decipher / understand what exactly it is
  • Obtain the signature of the patient/ attendant in the form at the appropriate place provided in the form
  • Do not suppress any information on the history of the ailments/ co-morbidities/ alcohol status
  • Always go by the tariff that you have filed with the TPA for the various charges being claimed
  • If you have not filed your tariff for the procedure being carried out (where it is a new procedure introduced) file the tariff for the procedure immediately with the TPA network team
  • Submit the pre-authorization request a couple of days in advance for planned admissions
  • Liaise with the pre-authorization team to know the status of the request
  • To ensure prompt attention and real-time status updates use online pre-authorisation submission model instead of the fax mode
  • Submit the documents as listed below during the preliminary pre-authorisation/ final pre-authorisation process to avoid shortfall
  • In the event of a shortfall raised by the approver, promptly submit the same
  • If the documents as called for in the shortfall request are not submitted, the TPA is authorised to close or the reject the Pre-authorisation request.
  • On receipt of the approval, please check if the approval is subject to any conditions like  

a.       Room rent cap per day

b.      Any other restrictions linked to the eligible room limit

c.       Ailment/ procedure cap

d.      Co-pay to be deducted

   

  • There will be standard conditions as below. Understand their significance – do not over-look:
    1. This authorization is valid only at the above hospital, for the diagnosis and treatment approved, provided admission falls within the date of admission as above. For any change in date of admission, diagnosis or the procedure/ treatment specific approval has to be obtained failing which this approval will be null & void.
    2. For enhancement of expenses approval must be obtained before patient is discharged
    3. Vidal Health Insurance TPA  is not liable for payment under this authorisation if the information provided during pre-authorization/ or the claim documents submitted by the hospital or insured is incorrect / revised
    4. Cashless access for hospitalization is only a facility extended by TPA subject to terms and conditions of the policy. Vidal Health Insurance TPA does not guarantee the quality, availability or outcome of treatment.
    5. Denial of cashless access is not to be considered in any way as a denial of treatment.
    6. Please collect all non-admissible expenses from the patient. Please visit our website for the list of non-admissible expenses.
    7. In case of maternity related hospitalization (a) claim will not be admissible if the person has two or more living children (b) well-baby care related charges to be collected from the patient.
    8. The claim settlement would be as per the tariff /discounts contracted in the network agreement
    9. The following claim papers should be submitted within 7 days from the date of discharge of the patient: (a) photo ID proof of patient (b) cashless approval copy with the voucher portion duly signed by the insured patient (c) detailed discharge summary (d) all investigation reports (e) operation notes (f) hospital final bill (g) detailed break up bill (h) copy of receipt given to the patient for the amount paid by him/her (i) copy of separate receipt issued for co-pay collected. If co-pay receipt is not submitted the claim will be denied and no liability under this authorisation attaches to us.
    10. The above payment is subject to applicable TDS.
    11. If the insured is found to be an HIV/ AIDS patient and if the same is not disclosed during the cashless facility obtained, the authorisation shall be null and void and no liability attaches to this authorisation.
  • Follow the IRDA circulated list of non-admissible expenditure to be collected from the patient before discharge. This will reduce the time taken by the TPA for processing the bills
  • Once the final authorisation request is sanctioned,

    a.      Keep the documents ready to be submitted for settlement

    b.      Obtain the signature of the patient/ attendant in the voucher portion of the final approval letter

    c.      Obtain the signature of the patient on the Discharege Summary and the Hospital Bills (at least the Main Bill)

                      d.      Obtain the Claim Form duly completed and signed by the Patient tobe submitted to us along with Claim Documents

    e.      Collect from the patient any other amount deducted by the TPA

  • Submit the claim papers as detailed below to the TPA on the next day for their immediate processing for settlement
  • Maintain a set of papers submitted in a claim folder till such time the settlement is received. This will avoid your running around for the document should the TPA seek another set or clarification on the claim submitted
  • A couple of days after claim submission, Check with the TPA whether they have received the claim documents for settlement.
  • To avoid misplacement/ non-delivery of the claim documents, ensure that you submit the papers through personal/ office courier weekly 3 times
  • Do not bunch all the papers submitted on a day together. Obtain acknowledgement for each case paper separately quoting the pre-authorization number
  • Once the settlement is received from the TPA please update your account and keep reconciling your bills receivable account – TPA-wise
  • Check bills receivable with the bills pending settlement at the TPA-end monthly
  • Should the settlement made be different from the amount approved, seek clarification from the TPA and square up your account – either by writing-off the amount deducted if you agree with the deductions and if do not agree with the deduction pl follow-up the same and close each issue within a month. Please do not stand on ego for resolving the issue and do not keep carrying forward the bills short received/ short settled for ever. The Insurers cannot reopen the cases once the financial year is closed and TPA’s cannot settle such cases.
  • Where you find the TPA has not received the claim documents sent for settlement of your claim, kindly submit one more set of papers – marking them ‘duplicate’ along with a copy of the POD/ courier / postal receipt
  • Under certain circumstances the papers submitted to the TPA may get lost at their end due to mix up with other documents. Should TPA seek one more copy, please submit another set of documents duly marking ‘duplicate’.
  • Should the TPA deny cashless facility in respect of a request without assigning any reason, pl do not insist on TPA giving the reason. Advise the patient to settle the bill and submit the papers to the TPA for a possible reimbursement.
  • In the event a claim facilitator is sent for verification of the case documents and collection of the same, kindly co-operate

 

Documents to be submitted

 

For Preliminary aproval

  • Pre-authorisation form duly completed in all respects 

a.       Signed by the insured/ patient

b.      Preferably the latest form – to adopt the IRDA designed form for all TPAs uniformly

  • ID Proof

a.       TPA ID card

b.      Any other additional card like:

                                                               i.      Voter’s ID

                                                             ii.      Unique identification number

                                                            iii.      DL

                                                           iv.      Pan card

                                                             v.      Employment ID card

  • Admission Notes – in cases where the patient is already admitted prior to seeking pre-auth request
  • Investigation Reports – USG/ haematology/ MRI/ x-ray - etc for

a.       Investigations undergone prior to hospitalisation

                                                               i.      Possibly at the same hospital or

                                                             ii.      Outside the hospital

b.  Investigations undergone immediately on admission prior to sending the request

                                                               i.      Possibly at the same hospital or

                                                             ii.      Outside the hospital

  • Blood Alcohol Reports – if available (especially for accidental injuries)
  • Consultation Papers

a.       OPD consultation paper, if any

b.      Outside the hospital

c.       Referral from a physician, if any

  • Medico-legal papers for accident cases

a.       MLC report

b.      Police FIR – if available

 

Documents required for final approval

 

  • Enhancement request with justification for enhancement of the amount – quote the Preliminary Authorisation Approval Letter number
  • Report on any changes in the Final Diagnosis/ change in the treatment administered/ history of the ailment/s
  • Detailed Discharge Summary indicating

a.      The Primary Diagnosis for which treatment has been administered – its history

b.      Secondary Diagnosis for which (possibly) treatment has been administered – their history

c.      Co-morbidities – their history

d.      Symptoms/ complaints on admission

e.      Tests conducted

f.       Treatment administered

g.      Discharge advice

  • Death Summary (instead of Discharge Summary) where the patient has passed away during hospitalisation
  • Investigation Reports – for all tests conducted – excluding the reports already sent for Preliminary Authorisation
  • Histopathology Report – wherever possible
  • Operation Theatre Notes – where surgery is performed
  • MLC  report/ FIR for accident cases – if not submitted at the time of Preliminary Authorisation
  • Sticker for the implants used
  • Supporting invoice for the implants used
  • Hospital Main Bill duly signed by the patient
  • Break-up bill for the hospital Main Bill – duly signed by the patient
  • Copy of the separate receipt for the co-pay amount collected
  • Copy of the detailed bill for the amount collected from the patient for the other non-admissible amounts
  • Copy of the receipt for the other non-admissible amounts collected from the patient
  • Preliminary pre-authorisation approval letter duly signed by the patient

 

Documents required for settlement for cashless approved

 

  • Preliminary Pre-authorisation request duly signed by the patient and the treating doctor - original
  • Copy of the Preliminary Pre-authorisation approval letter duly signed by the patient
  • Copy of the final enhancement approval letter duly signed by the patient in the voucher portion
  • Original enhancement request with justification for the enhancement of the amount
  • Report on any changes in the Final Diagnosis/ change in the treatment administered/ history of the ailment/s
  • Admission Notes – certified copy
  • OPD case papers/ consultation paper/ referral letter submitted during the Preliminary Pre-auth – certified copy
  • ID proof – submitted during Preliminary Pre-auth process - copy
  • Detailed discharge summary submitted for final enhancement - original
  • Death Summary (instead of discharge summary) where the patient has passed away during hospitalisation - original
  • Investigation Reports in original – done prior to admision and during hospitalisation submitted during Preliminary Authorisation as well enhancement
  • Histopathology Report in original
  • Certified copy of operation theatre notes – where surgery is performed
  • MLC report/ FIR for accident cases – certified copy
  • Sticker for the implants used - original
  • Supporting invoice for the implants used – certified copy
  • Hospital Main Bill duly signed by the patient- original
  • Break-up bill duly signed by the patient for the hospital Main Bill - original
  • Copy of the separate receipt for the co-pay amount collected
  • Copy of the detailed bill for the non-admissible amounts collected from the patient
  • Copy of the receipt for the amount collected from the patient for the non-admissible amounts
  • Your covering letter forwarding the claim paper – use separate letter for each case