Corporate & TPA

TPA Rules and Regulations

BAPS SHASTRIJI MAHARAJ HOSPITAL has tied up with the Third Party Administrators (TPA) to extend cashless facilities to the esteemed members of such TPA.
All completed forms for cashless authorization must be submitted to the business development unit or TPA/Corporate handling Unit within 24hrs of admission with supporting documents.
The cashless facility will be provided only to the extent of the approved amount as stated in the letter of authorization issued by the concerned TPA.
BAPS SHASTRIJI MAHARAJ HOSPITAL will provide an approximate estimate of expenses whenever required by the TPAs after submission of the completed form for pre-authorization by the patient.
BAPS SHASTRIJI MAHARAJ HOSPITAL will not be responsible if the TPA sanctions an amount lesser than what is stated in the estimate.
In case the final bill amount exceeds the approved amount by the TPAs , such excess amount shall be collected directly from the patient at the time of discharge .The same has to be followed in regard to the doctor’s/surgeon’s fees. Hospital will not be responsible in recovering or paying any such dues to the consultant.
BAPS SHASTRIJI MAHARAJ HOSPITAL, will however submit all such documents as may be necessary for further enhancement of the initial or subsequent amount as sanctioned earlier.
Only upon receipt of such enhancement letter, shall be patient be allowed to avail of the cashless facility.
Charges for accepting of the higher category of room etc. shall be levied at actuals in the event of any delay by the TPAs in sending the letter of authorization or further enhancement.
The patient must pay all the inadmissible expenses at the time of discharge. Such amount is to be paid even if it is well within the sanctioned limit. Identification of such inadmissible portion shall be at the sole discretion of the Hospital.
In case of denial of cashless facility the entire amount has to be paid by the patient at the time of discharge. BAPS SHASTRIJI MAHARAJ HOSPITAL is not responsible in delayed discharge due to end movement denials.
The patient fully understands that BAPS SHASTRIJI MAHARAJ HOSPITAL has no role in sanctioning the authorization amount for cashless facility. It is solely at the discretion of the TPA.
Any disputes arising shall be dealt directly by the patient or nearest relative with the concerned TPA.
The patient and his/her family fully understand that the payment has to be made to BAPS SHASTRIJI MAHARAJ HOSPITAL on demand in case the TPA/Company denies reimbursement to BAPS SHASTRIJI MAHARAJ HOSPITAL.

FAQ

IF I have I-card of the insurance company, does it make me eligible for cashless services?

NO. To avail a cashless facility just having I-card will not work. You will need to have the policy also. Suppose the employee is, a patient of a corporate which has group mediclaim then that employee has to carry his company ID card also. Under certain circumstances, it is quite possible that one may not avail of cashless facility.

Which documents are needed to avail cashless facility?

Previous two 2 years policy
ID card copy
If premium is paid by Cheque then copy of 64 VB certificate
In case of accident case patient has to give self-declaration
In case of police case copy of FIR
All previous check up, blood investigation & X-ray, USG, MRI reports

Is cashless facility available in every hospital?

NO. The insurance co. and the TPA consider the policyholder as their close family members and hence only after extensive survey, they empanel the hospitals. Such hospitals has needful infrastructure & they meet strict standards of quality. Our Hospital is on the panel of mostly all TPA’s.

Is cashless facility available for OPD consultation?

NO, cashless facility is not available for OPD consultation.

Do cashless services claims sometimes take more time than what is stipulated?

YES. If TPA Company needs more information about patient’s treatment or needs some specific reports. Then this takes more time than normal. But this does not happen every time & in most of the cases approval comes in a day or two.

After getting a cashless authorization with in how many days treatment should Start?

When TPA issue the Authorization Letter they already mention the admission date of patient (date which is fixed by the patient & the hospital authority & it is the same, mentioned in the admission request note). Usually Patient has to get admitted on that day only, but if for some reason patient cannot get admitted to the hospital; then in that case the hospital gets an extension of that date from TPA.

When TPA issues cashless Authorization does it put any restriction?

• Certainly, the restriction could be as under,
• Reduction in the amount asked ( depends on policy terms)
• Non allotment of special/ac/suit room
• Stay for necessary days only
• Ambulance charges are not reimbursed
• Personal expenses of patient
• If permission has been received for some particular treatment then claim can not be provide for other disease
• TPA puts this restriction as per the policy of the policy holders.
• Some of the non – admissible items are not approved (list can be made available form our TPA desk)

As per policy if patient is eligible for general room but wants a special room then What?

As per policy if patient is eligible for general room but wants a special room then the difference between the general & special room charges has to be paid by the patient to hospital from his pocket & this will not be reimbursed. The difference in amount shall be levied on all services availed as per the room category.

If I have a cashless mediclaim policy don’t I have to pay for anything?

The Authorization letter is issued only for the period between admission & discharge. So the pre hospitalization & post hospitalization expenses has to be borne by the patient.

In case the actual expense exceeds the authorization amount what can/should I do?

This happen many a time, if the expenses exceed than the authorized amount, patient has to pay the difference to the hospital & then reimburse /claim the amount from the TPA.

If I have spent money before availing cashless facility, what should I do?

The Authorization letter is issued only for the period between admission & discharge. So the pre hospitalization & post hospitalization expenses has to be borne by the patient.
30 days before you avail a cashless facility admission , whatever money patient has spent on medicines, x-rays, sonography, lab investigation etc. can be claimed, but all this expenses must be related to treatment for which patient was admitted.

If the treatment amount is exceeds than the policy amount what should I do?

If the treatment amount is exceeding than the policy amount then the exceeded expenses are to be borne by the patient (one cannot reimburse or claim this from the TPA).

If cashless Authorization is not given by TPA dose it means that I cannot Claim the Amount

No, it is not so always. In case the policyholder does not get cashless authorization from TPA, it does not mean that he cannot claim the treatment expense. Cashless authorization is given in cases, which are simple & strait forward. If the disease & treatment are beyond these conditions then cashless authorization is not given. Then personal claim can be made.

After doctor suggests discharge, can we leave immediately?

No, after the doctor suggesting discharge, the TPA department sends final bill to the TPA Company for approval. They constantly follow up for the status of the approval. However, during this period, the officer’s form respective TPA Company might come for the patient verification. In absence of patient, the chances of claim rejection are quite possible. Hence patient discharge is suggested after the receipt of with the final bill &communication of TPA personnel.

If treatment exceed more than two months then will I get claim Amount?

If treatment exceeds more than two months after discharge than patient has to take certificate from the Doctor, saying that the treatment is continuing till which time & all these details have to be conveyed to the TPA & by that expenses can be reimbursed.