Kalingarayan Hospitals' insurance policy,
procedures, and other aspects

The patient must come to the ground floor TPA Help Desk to turn in a copy of their insurance TPA ID card, proof of identity, proposer KYC documents, all investigation reports, and any consultation papers related to their current hospital stay. Two components of the pre-authorization form must be completed. Patients or their families must complete Part 1, and the hospital administration or treating physician must complete Part 2. It is necessary to mail the completed paperwork to the appropriate TPA or insurance. The initial authorization letter, whether allowed or rejected, will be emailed back to the hospital by the appropriate TPA/Insurance within four hours of receiving the preauthorization form.

Note:-

For planned hospitalisation: - Pre-authorisation form to be submitted before 72 hours of hospitalisation.

For Emergency: - Pre-authorisation form to be submitted to the TPA desk within 6 hours from the time of admission.

The hospital staff must transmit the final bill, breakdown, and discharge report to the appropriate TPA or insurance on the day of discharge. Within four hours of receipt, the augmentation will be handled in accordance with the terms and conditions of the insurance, after the patient's non-medical expenses have been subtracted. The hospital will receive an email with this approval letter.

Note:-

Co pay and Ailment Sublimit (if applicable) has to be paid by the policyholder

Once the shortfall is raised, Hospital will respond within 8 hours based on the query.

Non Medical expenses are: Admission fees, Registration fees, gloves, blade, water bed, food & beverages, extra bed etc.

Refer IRDA Non payable list as per Policy terms and conditions

Minimum 24 hours of hospitalization (if not day-care) with an active line of treatment is required for cashless treatment.

However, there are a few specific ailments specified in the policy which can be covered even though the period of hospitalization is less than 24 hours Such as Dialysis, Chemotherapy, Radiotherapy, Eye Surgery etc.

Rejection will be done as per the policy terms and coverage, These are a few reasons for rejection:

• If hospitalization is for observation & investigation purpose
• If any particular ailment/disease/treatment is found not covered under policy term and condition
• If found that the treatment can be done under OPD basis
• If found that no active line of treatment is available
• If Shortfall and the policyholder has not responded within the given TAT
• If policy is invalid
• Rejection of cashless is not a denial of treatment

If this occurs, the policyholder will be responsible for paying the difference. The policyholder's eligible amount will be communicated to the patient, and the hospital will collect the excess amount from the policyholder directly.

Policy holder has to intimate Respective TPA/Insurance before sending the claim documents if he/she wants to claim after discharge. Intimation has to be given within the TAT as per the insurance company.

The claim form must be downloaded by the policyholder from the appropriate TPA or insurance. The four-page claim form also includes a medical certificate. The treating physician must fill up the medical certificate, sign it, and include the hospital seal. The policyholder must complete the claim form, send it to the appropriate TPA or insurance (respective branches), and include all of his original bills.

The relevant TPA or insurance will evaluate the claim's validity based on the supporting documentation, verify the policy and the treatment received, and resolve the claim within the parameters of the claim settlement. The case would be dismissed if the claim did not follow the guidelines.

Yes, you will be intimated on your claim status on your updated email id from our Insurer database.

Visit TPA help desk or call customer care Toll-free for status of the claim

• Preauth form duly signed
• TPA/Insurance ID card
• Identity Proof (photo copy)
• Proposer KYC documents (AADHAR & PAN Card)
• last 4 years Policy Copy (applicable for retail policyholders)
• First consultation paper
• MLC /FIR copy for all RTA cases.
• Investigation reports like MRI, ECG, CT scan, and X-Ray etc – relevant to present admission
• Non Influence of Alcohol report from first treating doctor

Shortfall documents are those which are not submitted by the claimant/Hospital, and are mandatory for further claim process.

The amount which is not approved is disallowed amount such as Non medical expenses, aliment capping, exceeds Sum insured / aliment limit Etc

Day-Care surgeries are those which do not require 24 hours of hospitalization such as Cataract (Eye) surgery, Dialysis, Kidney stone removal, Chemotherapy, D&C etc.

Depending on Insurance policy some of the Day-Care surgeries are payable according to terms and conditions.

For queries: kindly visit TPA Help Desk situated in Ground floor near Blood Bank.

CUG Number: 8754081075/ 8754081094

Email Id:[email protected]