Swasthya Ratna Claim Procedure

1) Cashless facility can be availed or granted when the hospital is registered as Network hospital of TPA

  • Planned Hospitalization: When the Cashless request process is completed in advance
  • Unplanned/ Emergency Hospitalization: When the request for Cashless is given at the time of admission only

2) Reimbursement Facility: Reimbursement facility is generally availed if the hospital is not in network list of TPA or due to unclear requests cashless is not granted by TPA or if the insured voluntarily does not opt for Cashless facility.

Cashless Claims Process:

Planned/Unplanned cashless request

1) Cashless facility is only applicable if the employee goes to a network hospital

2) Employee should carry their mediclaim cards or mediclaim ids along with a photo id proof to the hospital.

3) Once in the hospital, go to the Help desk/TPA Desk/Reception, and inform that you are covered under Group Mediclaim Insurance Policy, and get the pre-authorization form filled by the doctor/hospital.

4) Get the filled form faxed/Email to the TPA

a) If everything is ok, within 2-4 hours the TPA will sanction the amount

b) If TPA requires more clarification, it will re-fax/Email the letter of requirement/clarification. The query needs to be answered satisfactorily via fax/Email. If the query is resolved, then TPA will sanction the cashless

c) The cashless may be rejected if TPA is of the view that ailment/ hospitalization is not covered under the popcy

05) If the final bill is more than initial sanctioned amount, then at the time of discharge follow the above process again. Additional limit will be granted if things are in order.

06) There are few hospitals which may ask for certain deposit amount at the time of admission which will be refunded to you once the hospital gets it payment from the TPA

Note

Denial of “Cashless Service” is not denial of treatment. You can continue with the treatment, pay for the services to the hospital, and later send the claim to TPA for processing and reimbursement.

Pre-authorization:

The process of approval of Cashless request is called Pre- authorization

  • Cashless request is to be sent on the day of admission or next day only. Cashless cannot be initiated on the day of discharge.
  • Faxing /Emailing of pre- authorization form may be followed by a phone call to TPA call center within 30 minutes to ensure that fax/Email has been received by them.
  • Please ensure that the form is completely filled, signed and stamped before sending it to TPA. Incomplete form will only delay in authorization. The form is to be filled by treating doctor/consultant.
  • TPA may revert with some more clarification on nature of ailment, past ailment, proposed treatment, expense, etc. Kindly ensure that the queries are replied immediately and faxed/Email to TPA.
  • Cashless will be granted and the Authorization Letter (AL) will be faxed/Emailed to the hospital.
  • If the process is taking too long and not to your satisfaction, then you may get in touch with representatives at Edelweiss Gallagher Insurance Brokers Ltd. (EGIBL) or at TPA or your respective HR coordinator
  • However kindly note that you/your representative is the best person to get the Pre- authorization form filled from the doctor/hospital authorities. EGIBL/HR will only be able to assist after the form has been faxed/Email to TPA.
  • The TPA Desk generally functions only till 5.30-6.00 in the evening. If hospitalization is in late evening, then the cashless request needs to be sent next morning (this will not hinder the treatment and it can be initiated)

Assistance during Cashless Procedure:

Contact points:

Email: hcm@edelweissfin.com

Phone:+91 22-6859 1803

Reimbursement (Non-Cashless) Process:

  • Reimbursement route can be availed if the hospital is not in Network list of TPA or any other reason due to which you don’t/can’t apply for Cashless process
  • Along with completely filled claim form, all documents/bills/reports in original are to be submitted directly to EGIBL within 7 days of date of discharge
  • If all the documents are in order, then the claim will be settled within 21 working days of receipt of documents by TPA
  • If there’s some deficiency in documentation, it will be informed to the Employee/HR Dept in the form of Deficiency Letter. Employees are requested to submit the documents as per deficiency letter to HR Dept./TPA within 7 days of issue of letter. If the documents are not arranged then 2 reminder letters each with 7 days grace period will be sent, if still pending the claim will be rejected and the file will be closed permanently.
  • In case of any clarification/inability to furnish documents, the employee may get in touch with HR Dept./TPA/EGIBL
  • Please note that the original documents will be retained by the TPA and hence employee is requested to keep a copy of document with him/her
  • The claim status can be checked on the website of TPA or can be checked by Emailing/calling the HCM team at Edelweiss Email : hcm@edelweissfin.com Dedicated helpline no. +91 22 – 6859 1803

Important Points to be noted- Cashless:

Cashless Facility:

  • In case of Planned hospitalisation, it is advisable to complete the Cashless formalities in advance. The cashless approval is valid till 15 days of issue
  • Fill the pre- authorisation form completely before faxing/Emailing it to TPA.
  • TPA generally reverts in 2-3 hours of receipt of fax/Email. If it takes more time you may contact TPA/HR/EGIBL and apprise about it. Preferably the fax/Email may be followed by a phone call to TPA after 30 minutes to check receipt of it.
  • Initial approval will be given. If the expenses increase during stay then at the time of discharge final bill, etc. needs to be faxed/Email to TPA again. The total admissible amount will be approved, and you will need to pay non-admissible amount.
  • Kindly note that additional amount cannot be sanctioned after the discharge. If any amount remains pending, then it needs to be brought up for Reimbursement.
  • Note: The cashless generally gets delayed for non-submission of following documents. Please ensure that these are submitted at the first instance itself:
  • 1) Investigation reports

    2) Photo id card of patient

    3) Detailed line of treatment

Important Points to be noted- Reimbursement:

Reimbursement Facility:

  • The original documents must be submitted within 15-20 days of discharge to TPA/EGIBL, otherwise the claim may be rejected.
  • All the Bills, Reports, Discharge Card, etc. would be required in original
  • Ensure that employee’s/patient’s name is written on each bill purchased from outside. Unnamed bills will be rejected
  • If any deficiency is noted in documents submitted, TPA will send Deficiency Letter within 3-4 days of receipt of documents, the Deficiency letter will have 7days grace period. This will be followed by 2 Reminder letters with another 7 days grace period each. In all circumstances the file should be complete within 45 days of date of discharge. If the documents are still not submitted then the claim will be rejected.
  • Note: The Reimbursement generally gets delayed for non-submission of following documents. Please ensure that these are submitted at the first instance itself
  • – Original Discharge Card

    – Original Bills/Receipt

    – Investigation report

Claims Document List:

Documents to be submitted for Reimbursement claim

All the documents mentioned below should be submitted to avoid any delay in claim or repudiation of claim

1. Original hospital final bill

2. Original pre-numbered receipts for payments made to the hospital

3. Complete breakup of the hospital bill

4. Original Discharge Card/Summary

5. All original investigation reports

6. All original medicine bills with relevant prescriptions

7. Original signed claim form

8. Photo ID card copy of claimant

9. Paginated copy of Indoor Case papers

10.FIR/MLC copy in case of Road accidents. If MLC is not applicable, then written confirmation from Doctor/Hospital that the patient was not under influence of alcohol or drugs

11. Duly filled & stamped claim form

12. Cancel cheque copy of employee

All the bills/reports/prescription are to be submitted in original. In case any query additional document may be asked apart from above mentioned list of documents.