Claims Guide

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Claim procedure

1. Cashless hospitalisation
Cashless Hospitalisation means the Administrator may authorize (upon an Insured persons request) for direct
settlement of eligible services and the corresponding charges between a Network Hospital and the Administrator. In
such case, the Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person
may not have to pay any deposits except for the non medical charges at the commencement of the treatment or bills
after the end of treatment to the extent these services are covered under the Policy

Note: In some preferred hospital, deposit amount is mandatory which can be refunded at the time of credit payment
settlement by the hospital.

a) Pre-authorisation process

Step 1

The insured employee shall call the call center numbers and give the following details.

Insured employee shall approach TPA desk counter to complete preauthorisation formalities by showing Photo id
proof of the claimant and mediclaim card.

Name of Employee

Employee I.D. Number

Ailment/Surgery/for which he intends to be hospitalized for

Preferred name and address of the network hospital

Step 2

The pre authorisation form should be filled by the treating doctor in consultation with the insured and then send it to
the TPA.

Step 3

TPA would then internally check on the hospital, the estimated amounts quoted and the eligibility of the employee
and issue an authorisation/query/denial letter to the network hospital.

Step 4

The medical bills of the hospital would be directly forwarded to United Healthcare TPA and processed by them for
payment. Bills that are not settled through the cashless mechanism will have to be settled via reimbursement with
the appropriate documents (Refer to the document check-list given below)

Note: Maternity can be cashless or reimbursement. All maternity claims should be pre-authorized in case of
cashless. However, in case you go for reimbursement under an emergency C section or non-network hospital, you
are required to provide justification for the same with supporting documents. Failing to do so will result in a 10% co
pay on the total claimed amount.

b) Planned hospitalisation

Step 1
All non-emergency Hospitalisation instances must be pre-authorized with the TPA. This is done to ensure that the
best healthcare possible, is obtained, and the insured member is not inconvenienced when taking admission into a
Network Hospital.
Step 2

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After your Hospitalisation has been pre-authorized, you need to secure admission to a hospital. A letter of credit will
be issued by TPA to the hospital. Kindly present your ID card at the Hospital admission desk. The insured member
is not required to pay the hospitalisation bill except for the non medical charges in case of a network hospital. The
bill will be sent directly to, and settled by, TPA.
Note: Patients seeking treatment under cashless Hospitalisation are eligible to make claims under pre and post
Hospitalisation expenses. For all such expenses, the original bills, payment receipt and other required documents
need to be submitted separately as part of non-cashless claims.

c) Emergency hospitalisation

Step 1
In cases of emergency, the member should get admitted in the nearest network hospital by showing their Mediclaim
ID card & Photo ID Proof and initial deposit as per hospital rules. The treatment should not be put on hold
irrespective of the time of receipt of pre-authorisation.
Step 2
Relatives of admitted member should inform the call centre within 24 hours about the Hospitalisation & seek pre
authorisation. The pre authorisation letter would be directly given to the hospital. In case of denial, member would
be intimated by TPA medical doctor.
Step 3
After your Hospitalisation has been pre-authorized, the employee is not required to pay the Hospitalisation bill in
case of a network hospital, except for the non medical charges. The bill will be sent directly to, and settled by, TPA.

2. Non cashless hospitalisation

Admission procedure

In case you choose a non-network hospital, you will have to liaise directly for admission after the commencement of
the treatment please submit all original documents (as per checklist) for reimbursement and retain photocopies for
future reference.

Discharge procedure

In case of non network hospital, you will be required to clear the bill and submit the claim to TPA for reimbursement
from the insurer. Please ensure that you collect all necessary documents such as discharge summary, investigation
reports etc. for submitting your claim (Pls refer checklist for assistance).

Submission of hospitalisation claim

Step 1
After the Hospitalisation is complete and the patient has been discharged from the hospital, you must submit the
final claim within 30 days from the date of discharge from the hospital.
Step 2
Under Hospitalisation claims, you are also permitted to claim for treatment expenses 30 days prior to Hospitalisation
and 60 days after the date of discharge. This is applicable for both network and non-network Hospitalisation. This
documents needs to be submitted to the TPA within 10 days from the completion of the Post hospitalisation
treatment or whichever is earlier. However please note the expenses should be related to the same ailment for
which the hospitalization had taken place.

Claims check-list
Claim Documents to be submitted for reimbursing a claim

Signed Claim Form & Photo ID Proof of the claimant

Main hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the
original payment receipts

Discharge summary (original)

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 Attending doctors bills and receipts and certificate regarding diagnosis (if separate from hospital bill)

All original bills, investigation reports, medicine bills and prescription of the doctor this is usually mentioned in
the discharge summary. (Not required)

Break up with details of pharmacy items, materials, investigations even though it is there in the main bill

In case the hospital is not registered, please get a letter on the hospital letterhead mentioning the number of
beds and availability of doctors and nurses round the clock

In case of non-network Hospitalisation, please get the hospital and doctors registration number in hospital
letterhead and get the same signed and stamped by the hospital

Retain photocopies for future reference

Note: The above mentioned list is a standard check-list. Additional documents may be required depending on the
nature of the case. The same will be reviewed on a case to case basis and shall be communicated via United
HealthCare TPA

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