EMPLOYEE BENEFIT MANUAL

Medical Benefit – Cashless Process

Cashless means the TPA may authorize upon a Policyholder’s request for direct settlement of eligible
services and it’s according charges between a Network Hospital and the TPA. In such case the TPA will
directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to pay
any deposits at the commencement of the treatment or bills after the end of treatment to the extent as these
services are covered under the Policy.

Planned Hospitalization

Emergency Hospitalization

Note : Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all
such expenses the bills and other required documents needs to submitted separately as part of the claims reimbursement.
 Planned Hospitalization
Step 1 Member intimates TPA of the Claim TPA authorizes cashless
Pre-Authorization planned hospitalization in a Registered by Yes as per SLA for planned
specified pre-authorization format the TPA on hospitalization to the
at-least 48 hours in advance same day hospital
All non-emergency hospitalisation
instances must be pre-authorized No
with the TPA, as per the
procedure detailed below. This is
done to ensure that the best
healthcare possible, is obtained, Follow non cashless Pre-Authorization
and the patient/employee is not process Completed
inconvenienced when taking
admission into a Network
Hospital.

Step 2 Member produces ID Member gets treated

Hospital sends
Admission, Treatment & card at the network and discharged after
complete set of claims
discharge hospital and gets paying all non entitled
documents for
admitted benefits like
processing to TPA
After your hospitalisation has refreshments, etc.
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 Turn Around Time for Approval: 2-4 Hours on Claims Processing &
Settlement by TPA &
employee is not required to pay receipt of complete information. Insurer
the hospitalisation bill in case of a
network hospital. The bill will be
sent directly to, and settled by
TPA

Next
 Emergency Hospitalization & Process
Step 1
Get Admitted
In cases of emergency, the
member should get admitted in P
the nearest network hospital by R
showing their ID card. O
C Member gets admitted in Pre- No
E the hospital in case of authorization Reimbursement
S emergency by showing given by the process
Step 2 S his ID Card TPA
Pre-Authorization by hospital
Yes
Relatives of admitted member
should inform the call centre within
24 hours about the hospitalization
& Seek pre authorization. The Member/Hospital applies Member gets treated and
preauthorization letter would be for pre-authorization to discharged after paying all
directly given to the hospital. In the TPA within 24 hrs of non medical expenses like
case of denial member would be admission refreshments, etc.
informed directly

Step 3 TPA verifies applicability of Hospital sends complete

Treatment & Discharge the claim to be registered set of claims documents
After your hospitalisation has and issue pre-authorization for processing to the TPA
been pre-authorized the
employee is not required to pay
the hospitalisation bill in case of a
Turn Around Time for Approval: 2-3 Hours on
network hospital. The bill will be
sent directly to, and settled by receipt of complete information.
TPA
Reimbursement
Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for
reimbursement of hospitalisation expenses from the insurer.

Discharge procedure
• In case of non network hospital, you will be required to clear the bills 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. in original for submitting your claim.

Intimation & Submission of hospitalisation claim

▪For all reimbursement claims, employees need to intimate TPA either through the call center or through
the website.

• You must submit the final claim with all relevant documents within 30 days from the date of discharge
from the hospital.

Claims Process Claim Docs

 Reimbursement Claims Process
Insured admitted as per Insured sends relevant
hospital norms. All payments documents to TPA office A
made by member within 30 days of discharge

Is document
received
Is claim TPA performs medical scrutiny
within 30
payable? of the documents •Insured will create the
Yes days from
summary of Bills and
Yes discharge
attach it with the bills
No No •The envelope should
contain clearly the
Employee ID & Employee
Claim Rejected e-mail

Is Payment to be made to
TPA checks document documentati Employee. The discharge
Claims processing done
sufficiency on complete Yes voucher and copy of payment
as required receipt to be sent to employee
through TPA Helpdesk.
No
Send mail about deficiency
and document requirement to A
the employee

Next
Claims Document List
Completed Claim form with Signature

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

Discharge Report (original)

Attending doctors’ bills and receipts and certificate regarding

diagnosis (if separate from hospital bill)

Original reports or attested copies of Bills and Receipts for

Medicines, Investigations along with Doctors prescription in
Original and Laboratory

Follow-up advice or letter for line of treatment after discharge

from hospital, from Doctor.

Provide Break up details including 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 non- network hospital, you may have to get the hospital and
doctor’s registration number in Hospital letterhead and get the
same signed and stamped by the hospital, if required.

*Please retain photocopies of all documents submitted

 Claim Submission & Intimation

• For all reimbursement claims, employees need to intimate

TPA either through the call centre or through the website.

• All reimbursement hospitalization claims need to be

submitted 30 days from the date of discharge from hospital

• All pre & post hospitalization claims need to be submitted

within 90 days from the date of discharge from hospital
 Utilization of Benefit

➢ Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost caution and
prudence.
➢ The ever increasing cost for the benefits require a proactive involvement from all of us.
➢ The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents covered

Please ensure to crosscheck the final bill sent to the TPA for the following:

✓You are Billed only for the services utilized for e.g. category of room, diagnostics undergone ,
medicines consumed

✓Total of the bill

In case of any planned hospitalization, approach the hospital in advance(48 hrs) and request pre
authorization- this enables TPA to further negotiate the rates

To approach hospitals with caution – most expensive is not necessarily the best.

To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an
idea general spend for the treatment or procedure.

Try to negotiate , Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)
Mediclaim Policy – Contact Details

Important Details
Hospital Network List
List of hospitals in the Care Health network eligible for
cashless process
Call Centre Toll Free number (24/7) –
1. Click on Website – 1800-200-4488
https://www.careinsurance.com/health-plan-
certified-network-hospitals.html

SPOCS:
Email -
1st Escalation Points corporateassistance@careinsurance.com

Ms. Prince Bhatia (bhatia.prince@careinsurance.com ),

Mobile No: 9821870746

Ms. Monika Singh (monika.singh@careinsurance.com),

Mobile No: 8376860077
THANK YOU