Medical insurance claim procedures involve the process of seeking reimbursement or cashless treatment for medical expenses incurred by the policyholder. Here is a summary of how the procedure works:
Choose a network hospital approved by your insurance company.
Inform the third-party administrator (TPA) in advance and provide your membership number.
Fill out a cashless request form at the hospital.
Submit the form and necessary medical records to the TPA.
The TPA will review the documents for approval.
Once approved, the insurance company will directly settle the hospital bills.
If disapproved, you can opt for reimbursement instead.
Select a network hospital mentioned in your insurance policy.
Notify the TPA at least three days before admission and provide your membership number.
Complete the cashless request form at the hospital.
Submit the form and medical records to the TPA.
The TPA will review the documents.
If approved, the insurance company will settle the hospital bills (excluding non-covered charges).
If disapproved, you can file for reimbursement.
In case of emergency, inform the TPA and provide your membership number.
Fill out the cashless form at the hospital, certified by a doctor.
Send the form along with medical records to the TPA.
If the cashless facility is approved, the hospital bills will be settled directly.
Seek reimbursement if the cashless request is disapproved.
Pay for the treatment upfront.
Contact your insurance company through the toll-free number and provide your membership number.
Keep all the bills, prescriptions, discharge summary, and other necessary documents for reimbursement.
Download and fill the reimbursement form from the insurance company's website.
Submit the filled form along with the medical records to the insurance company.
Once the claim is approved, the insurance company will disburse the reimbursement via check.
The typical processing time is around 20 days from the receipt of all the required documents.
Fill out the claim forms accurately to avoid claim denials.
Initiate the claim request within seven days of the patient's discharge.
Some items may not be covered under the policy and will not be reimbursed.
Keep all the necessary documents ready, as the insurance company may request them at any time.