How many times do you remember getting a call from a friend or a relative telling about an emergency hospitalization and need of cash? You rush, many times in the middle of night to the nearest ATM and retrieve thousands of rupees that are required for getting yourself admitted in today’s good quality hospitals. Cashless Hospitalization Service is a facility which is designed specifically to avoid these- panicky and tensed moments during hospitalizations.
How does Cashless Service work?
In Cashless health insurance Service, when you get hospitalized with a network hospital, you do not have to settle the bill with the hospital. The Insurance Company represented by the TPA, co-ordinates with the hospital and settles the bill.
Health insurance companies make tie-ups with hospitals after negotiating their rates and checking their quality. These hospitals are called as Network Hospitals; Cashless service is available only in these hospitals. To know which hospitals are in your health insurance provider’s network, check the name of your TPA in the policy and visit its website or call their toll free number.
TPA or Third Party Administrators are the representatives of the health insurance companies who are responsible for settling the claims both reimbursement claims as well as cashless claims. It is the TPAs who have to approve your request for cashless and provide the service.
Pre-authorization form is the form that you get at the insurance desk in the hospital or in the website of the TPA, after being duly filled by the patient and the hospital’s representatives, it is sent to the TPA which decides to approve or reject the claim.
Process for Cashless Facility
In a planned hospitalization, you have a recommendation for hospitalization by your doctor and have time to decide which hospital to go to. You have to complete the formalities at least 3-4 days before you are hospitalized.
- Take a look at the list of network hospitals provided while buying the policy or call the toll free number on your health insurance card and select the network hospital nearest and most convenient to you.
- Show your health insurance card and fill up the first part that is to be filled by the patient of the ‘pre-authorization’ form that you get in the insurance desk of the network hospital or which you can download from website of your TPA.
- The other part of the form will be filled by the attending physician.
- Provide the filled form on the insurance desk of your hospital, the person at the insurance desk will verify its completeness and then fax it to the TPA.
- The TPA will then process the form and either approve or reject the request.
- If your form is approved, the TPA will send the authorization letter with an approved amount for the treatment.
- You have to follow up with the TPA to know the status of the request.
In an emergency hospitalization, the important thing is to get the patient treatment at the earliest. You need to start the procedure for cashless mediclaim facility within 24 hours of hospitalization.
- Show your health insurance card and fill in the pre-authorization form.
- The insurance desk in the hospital will fast track the process for your cashless process but in case you cannot wait for the approval, you can pay the deposit if demanded by the hospital and start the treatment and reimburse the expense later on.
- Generally the time to taken to process an emergency case is 6 hours. You need to follow up with the TPA to know the status of the request.
What is not paid?
You may notice that even with the cashless service, there are some expenses that you will have to bear, these expenses are:
- Registration or admission fee
- Visitors/ Attendant’s fee
- Charges for diet
- Ambulance charges
- Document charges
- Service charge
- Expenses for Tena pads, diapers, oxygen masks, nebulizers which are considered under medicines category.
Why is the request for Cashless rejected?
- If the ailment for which you are hospitalized is not covered in your policy.
- If the information contained in pre-authorization form is insufficient to approve the request, though most of the time the TPA will request the hospital if additional information is needed.
- If you have exhausted the sum assured for that year.
What if the cost for treatment exceeds the approved sum?
Generally the TPA only approves a part of the expenses of the treatment and only after the hospital sends the final bill along with the discharge summary and other reports does it approve the entire amount.
Sometimes the hospitals will request the TPA to increase the amount approved if needed during the treatment.
Some pointers about the Service
- Cashless service is only available in network hospitals.
- All the medical documents including the lab reports, claim forms, discharge summary and final bill has to be submitted to the hospital before being discharged.
- To ensure that your request is not rejected, send a completely filled pre-authorization form and send it within the required time frame.
- If the TPA does not approve your request, you can pay the bill now and reimburse it later.
- Cashless facility is subject to the conditions and terms in the policy.
Cashless is an excellent facility for customers and takes away some of the stress and tension during the hospitalization.