Scribd Logo
Upload

Welcome to Scribd!

  • 54 views

    ECHS Claiming

    Uploaded by

    Indraneel Namuduri
    The 8 step process for insured individuals to receive cashless treatment through Raksha Health Insurance TPA is outlined. Key steps include: 1) Confirming the hospital is in-network by checking the website or calling. 2) Presenting identification and insurance documents at the hospital. 3) Completing a pre-authorization form with patient and doctor details for treatment approval. 4) The hospital faxes/emails the form and documents for consideration of interim approval. 5) A unique claim number is generated upon registration of the request. 6) The claim is reviewed and an authorization letter may be issued for interim approved amount based on policy terms. 7) Final claim processing occurs after discharge when

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ECHS Claiming

    Uploaded by

    Indraneel Namuduri
    54 views2 pages
    The 8 step process for insured individuals to receive cashless treatment through Raksha Health Insurance TPA is outlined. Key steps include: 1) Confirming the hospital is in-network by checking the website or calling. 2) Presenting identification and insurance documents at the hospital. 3) Completing a pre-authorization form with patient and doctor details for treatment approval. 4) The hospital faxes/emails the form and documents for consideration of interim approval. 5) A unique claim number is generated upon registration of the request. 6) The claim is reviewed and an authorization letter may be issued for interim approved amount based on policy terms. 7) Final claim processing occurs after discharge when

    Original Title

    ECHS-claiming

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The 8 step process for insured individuals to receive cashless treatment through Raksha Health Insurance TPA is outlined. Key steps include: 1) Confirming the hospital is in-network by checking the website or calling. 2) Presenting identification and insurance documents at the hospital. 3) Completing a pre-authorization form with patient and doctor details for treatment approval. 4) The hospital faxes/emails the form and documents for consideration of interim approval. 5) A unique claim number is generated upon registration of the request. 6) The claim is reviewed and an authorization letter may be issued for interim approved amount based on policy terms. 7) Final claim processing occurs after discharge when

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    54 views2 pages

    ECHS Claiming

    Uploaded by

    Indraneel Namuduri
    The 8 step process for insured individuals to receive cashless treatment through Raksha Health Insurance TPA is outlined. Key steps include: 1) Confirming the hospital is in-network by checking the website or calling. 2) Presenting identification and insurance documents at the hospital. 3) Completing a pre-authorization form with patient and doctor details for treatment approval. 4) The hospital faxes/emails the form and documents for consideration of interim approval. 5) A unique claim number is generated upon registration of the request. 6) The claim is reviewed and an authorization letter may be issued for interim approved amount based on policy terms. 7) Final claim processing occurs after discharge when

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Sainik Seva Samiti

    ECHS Process

    Insured or Patient needs to confirm whether the hospital in which he/she is seeking treatment is on Raksha Health Insurance TPA network either
    Step 1
    by logging on to website www.rakshatpa.com and navigating to the tab “Network Hospital” or calling on our 24X7 Call Centre.

    If hospital is on network, then patient/insured needs to carry his/her physical or E-card along with a government photo id proof (preferably
    Step 2 Aadhaar Card), Pan Card as per KYC & AML norms along with treatment related documents like first OPD prescription, medication papers,
    investigation reports (if any) or any other medical documents related to treatment.

    Insured/Patient needs to declare at hospital details of insurance cover he/she has with insurance co. along with TPA details, post which the
    Hospital TPA Support Desk would provide a pre-authorization form in which personal details need to be filled by insured/patient and rest of details
    Step 3 need to be filled by treating doctor and hospital staff. Insured/Patient needs to opt for room as per their policy eligibility only. A declaration form
    also needs to be signed by insured/patient. Insured/Patient needs to submit treatment related documents (OPD prescription, medication
    documents or investigation reports) at the Hospital TPA Helpdesk. Preauthorization form needs to be signed by the patient or his family member

    Hospital would fax/email the duly completed, signed (by insured and treating doctor) and stamped (having diagnosis details, estimated cost, room
    Step 4 rent opted) along with declaration form, past medical records (if any), Raksha card copy and govt. identity card copy (duly stamped) for
    consideration. Insured/Patient can take approval 7 days prior to hospitalization in case of planned hospitalization and within 24 hours of
    hospitalization in case of emergency hospitalization.

    After receiving fax/email, a validation of coverage through policy no./Raksha Member ID on card, the request will be registered, and unique
    Step 5
    cashless claim no. would be generated.

    The claim documents will be reviewed by claim processor/s and admissibility will be governed by the policy terms and conditions along and on
    Step 6 basis of medication protocol, hospital agreed tariff.

    After review, if claim is admissible an Authorization Letter (A/L) would be issued to respective network hospital confirming the interim authorized
    Step 7 amount. Insured/Patient should note that this A/L is not final confirmation on admissibility of claim which can only be concluded once discharge
    summary having detailed treatment given along with hospital final bill is shared.

    Step 7 (i) - In case of any deficiency, Raksha will raise query to hospital. The query should be resolved within 24 hours. Once reply is received,
    the claim will be re-assessed based on merits and as per your policy terms and conditions and claim processing guidelines of your insurance
    company.

    Step 7 (ii) – If admissibility of the claim cannot be established based upon the documents provided at the time of cashless request, the cashless
    facility shall be denied. However please note that denial of authorization for cashless benefit does not mean denial of claim or denial of treatment
    and does not in any way prevent you from seeking necessary medical attention or hospitalization. The insured/patient can submit the claim
    documents for reconsideration in reimbursement along with duly completed claim form within 7 days from date of discharge from the hospital.

    At time of discharge, hospital would send all hospitalization related documents along with discharge summary, final bill, reports, medicine details
    Step 8
    etc. & claim would be processed as per step 7 with consideration of hospital tariff, package, or schedule of charges, mutually agreed\ upon with
    either Raksha/GIPSA or Private Insurance Companies, whichever is applicable as per policy. Insured should note that the policy may contain
    certain exclusions &/or restrictions which will be applied at the time of initial & final authorization. Non-medical expenses (NME are not payable
    and will be deducted.
    Reimbursement
    Claim Process

    Within 30 days after discharge, please lodge your claim with Raksha for processing. When lodging your claim with
    Raksha, please make sure that all the documents listed below are sent.

    ✓ Claim form duly signed by the insured.


    ✓ Copy of your E-card.
    ✓ Copy of cancelled cheque/ Corporate account
    ✓ Copy of Govt. photo id proof of the patient and PAN card of the main member.
    ✓ Copy of corporate ID card
    ✓ Hospital bills in original. For all consolidated amounts, the detailed breakup of the billed amount is required from the hospital.
    ✓ Original cash paid receipt of the final bill.
    ✓ For medicines purchased outside, the bills should be accompanied by a prescription from the doctor.
    ✓ Discharge summary or card in original.
    ✓ All investigation reports in original.
    ✓ In case of surgical packages – detail breakup of the package.
    ✓ Pharmacy bills and breakup.
    ✓ Prescriptions if any.
    ✓ Payment Receipt of the Final Bill
    ✓ MLC Certificate from the hospital in the case of Road traffic accident. Or a certificate from the treating doctor mentioning that
    the patient was not under the influence of alcohol at the time of Accident.
    ✓ Attested Photocopy of indoor case papers with sign and stamp of the hospital.

    Mandatory documents for reimbursement of pre/post claim. The documents should be submitted
    within 7 days from completion of post limit (60 days) period.

    ✓ Duly filled claim Form


    ✓ E-card of the patient
    ✓ Any valid photo Id of the patient (photocopy copy) like Voter ID, DL etc. and PAN card of the main member.
    ✓ Company ID of the employee(photocopy)
    ✓ All Original Investigation Report (if any for pre-post period)
    ✓ All consultation Receipt if any with prescriptions of the doctor for same date. (Original Copy.)
    ✓ All the medicine bills with prescription of doctor (original)

    Intimation For ECHS claim document check list for SSS.

    For reimbursement cases intimation should be given to Raksha on ✓ Claim form A and Claim form B.
    [email protected] within 24 Hrs. of admission. ✓ Intimation copy made to TPA at the time of Admission.
    ✓ ID and address proof of insured and patient.
    Kindly Courier all the original documents to the Undersigned Address. ✓ Copies of claim documents attested by Hospital. (Bill copy Mandatory)
    ✓ Original Balance Payment receipt.
    ✓ Cancelled cheque.

    You might also like