Claim process.pdf

Health Insurance Policy(Employees Policy)

Stay Healthier with us 1

Raksha TPA

PROCESS FLOW - CASHLESS


Raksha TPA

How to avail Cashless Services


Emergency

Identification via UHID Cards

Approach Network Hospital

Planned

Pre-authorization request to

Raksha TPA from Provider

Raksha TPA Pvt Ltd

VERIFIED BY

DOCTOR

Authorization Issued Pre – Authorization Request Denied Queries Raised for

further Clarification

Raksha TPA

PROCESS FLOW - REIMBURSEMENT


Raksha TPA

EMERGENCY

APPROACH TO NON - NETWORK HOSPITAL

PLANNED

INTIMATE 3-4 DAYS BEFORE ADMISSION

INTIMATE WITHIN 24 Hours from ADMISSION or BEFORE

DISCHARGE

Hospitalization through Non-Network Provider (Reimbursement Claims)


Raksha TPA Pvt Ltd

SUBMIT DOCUMENTS IN 7 DAYS FROM D.O.D

Raksha TPA

PROCESS FLOW - CLAIMS


Raksha TPA

RAKSHA PROCESSING OF NON-NETWORKING CLAIMS INSURED (REIMBURSEMENT with

intimation in 24 hours from admission

CLAIM RECEIVED BY RAKSHA TPA PVT. LTD (within 15 days

from D.O.D.)

AUDITING

ENTRY ON LOCAL WEBSITE

DOCTOR’S OPINION

PASSED

QUERY NON PAYABLE

FINANCE DEPARTMERNT

Raksha TPA


MUST KNOW


Raksha TPA

DO’S (Cashless Services) Pre-auth form should be sent along with insured/attendant cell no. duly signed

by treating doctor/hospital.

Avail cashless treatment at Network hospitals for the covered ailments within eligible amount under the policy.

Leave back all the original documents and signed claim form with the network

hospitals at the time of discharge.

Contact local Raksha office in case of any query.

Make payment to the network hospital for the expenditure over and above sum insured/ specified limit for any disease, and for the expenses/treatment not covered under the package

For current status of empanelment/de-empanelment of networking hospital, please refer our website: www.rakshatpa.com


Raksha TPA

http://www.rakshatpa.com/

DONT’S (Cashless Services) Don’t insist upon admission for investigations or evaluation or health

check-ups.

Don’t carry back any original document at the time of discharge from the hospital.

Don’t forget to sign on claim form.


Raksha TPA

Document Checklist (Re-imbursement) After discharge policy holder has to submit the following documents to Raksha

TPA within 15 days.

Original detailed discharge summary

Payment receipt in original

Copy of ID card

Original hospital bill with breakup

Package break-up (if applicable)

Original investigation reports

Pharmacy bills with prescription

Claim form duly signed

Hospital registration certificate

Scan copy of cancelled cheque to be mailed at [email protected]


Raksha TPA


Day Care Treatments covered under Policy

Expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, such as:

Appendectomy

Haemo dialysis

Coronary angiography

Hydrocele

Coronary angioplasty

Hysterectomy

Inguinal/ventral/ umbilical/femoral hernia

D&C

Parenteral chemotherapy

Eye surgery

Piles/ fistula

Fracture/ dislocation excluding hairline fracture

Sinusitis

Lithotripsy

Tonsillectomy

Incision and drainage of abcess

Liver aspiration

Colonoscopy

Sclerotherapy

Prostrate

Radiotherapy

Or any other surgeries / procedures agreed by the TPA/ Company which require less than 24 hours hospitalisation and for which prior approval from TPA is mandatory.

Note: Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours

Raksha TPA


Eligibility for Hospital / Nursing Home

Minimum 15 in-patient beds (in metros) & 10 in Remote areas.

Fully equipped OT

Fully qualified nursing staff round the clock

Fully qualified & registered doctor(s) round the clock

Raksha TPA


General Exclusions Under the Policy

Domiciliary Hospitalization OPD treatment Treatment related to infertility, Voluntary Termination of

Pregnancy External Accessories (e.g.) Walking Stick, Crepe bandage,

Spectacles, contact lens, hearing Aids etc. Non Medical Expenses (e.g.) Telephone Charges, Food Charges,

Registration Charges, Accommodation Charges for Relatives. Naturopathy Treatment , Homeopathic & Ayurvedic Treatment War Like operations whether declared or not Circumcision unless necessary for treatment of disease Cosmetic treatment Plastic Surgery

Raksha TPA


General Exclusions Under the Policy

Dental Treatment other than arising due to Accident requiring hospitalization

Intentional Self Injury, Intoxicating Drugs, Alcohol, Congenital External Disease, sterility etc

Hospitalization meant for Oral Medication, primary Investigation is non Payable

Vitamins And Tonics unless part of treatment

Hospitalization Less than 24 hrs other than day care treatments

Pre & Post Hospitalization charges for Maternity is Non Payable

All Expenses related to the treatment of AIDS is not covered.

Raksha TPA


Raksha TPA

Claim process.pdf

Documents

Transcript of Claim process.pdf