Modification of existing format for “Request for Cashless Hospitalization f

Oililifi \11{ff14 ~ P4Pi41'1cfi ~ ffl ~ INSURANCE REGULATORY AND ir.lai DEVELOPMENT AUTHORITY OF INDIA Ref: IROA/HL T/REG/CIR/86/05/2019 27.05.2019 To All Insurers and TPAs, Re: Modification of existing format for "Request for Cashless Hospitalization for Health Insurance Policy (Part C)" and introduction of Standard Cashless Authorization Letter Format (Part D) 1. Reference is invited to clause 4 of the Circular ref: IRDA/TPA/REG/CIR/059/03/2016 dated 28.03.2016 issued under the provisions of IRDAI (TPA - Health Services) Regulations, 2016. Annexure 30 of the within referred circular prescribed three claim forms namely; Part A, Part B and Part C. 2. In partial modification of Part C (request for cashless hospitalization for Health Insurance policy), the revised "Part C" is herewith specified. 3. Part D - Cashless Authorization letter Format is now introduced for issuing to the Network Providers at time of authorizing the cashless treatment. All the Insurers and the TPAs shall ensure that every network provider is notified about the cashless authorization in Part - D specified and a copy of Part D is also simultaneously notified to the policyholder/claimant to enable the policyholder / claimant have information about the package rates agreed with the network provider or the extent of authorization issued to the network provider and related conditions thereof. As and when any supplementary / additional authorization or final approval is issued and notified to the network provider, copy of Part - D shall be also invariably notified to the policyholder. 4. Insurers and TPAs may endeavor to obtain PART-C from the hospitals by electronic/ digital means for seamless processing of the cashless requests. 5. Insurers and TPAs may also endeavor to notify Part - D to the network providers and the policyholders through system generated form and may specify accordingly, wherever may be the case. 6. All Insurers and TPAs shall ensure that the font size of these forms is not less than Times New Roman 10 and shall be clear and legible. 7. Insurers and TPAs may capture details of Part - C and Part - D in Optical Character recognition (OCR) / Machine readable format. Page 1 of 11 .fcf ;( 11511, ~ ~ • .:i ,,M',, I ii 15 I, ~-500 032, 'lfTTr'f Survey No. 115/1, Financial District, Nanakramguda, Hyderabad-SQQ 032, India Q) : +91-40-2020 4000,m : +91-40-2020 4555 6) : +91-40-2020 4000, Fax: +91-40-2020 4555 ~ : www.irdai.gov.in Website : www.irdai.gov.in 8. The Insurer and TPAs may specify any additional terms in Part - D subject to the Service Level Agreement entered with the network provider. 9. This Circular would come into effect from 1st July, 2019 (OVS Ramesh) General Manager (Health) Encl: Part- C & Part - D REQUEST FOR CASHLESS HOSPITALISATION FOR HEAL TH INSURANCE POLICY PART - C {Revised) (TO BE FILLED IN BLOCK LETTERS) DETAILS OF THE THIRD PARTY ADMINISTRATOR/ INSURER/ HOSPITAL: a. Name ofTPA/lnsurance company: b. Toll free phone number: c. Toll free fax: d. Name of Hospital: i. Address ii. Rohini ID iii. e-mail id TO BE FILLED BY INSURE DIP A TIENT A. Name of the Patient: B. C. D. Gender: Age: Date of Birth: E. Contact number: F. Contact number of attending Relative: 0Male □Female (Years) I (Month) (DD/MMNYYY) 0 Third Gender ------------------------ - G. Insured Card ID number: H. Policy number/Name of Corporate: I. Employee ID: J. Currently do you have any other mediclaim /health insurance: D Yes i.Company ame: ii.Give Details: K: Do you have a family Physician: L: Name of the Family Physician: M: Contact number, if any: N: Current Address of Insured Patient: 0: Occupation of Insured Patient: 0Yes □No (PLEASE COMPLETE DECLARATION OF THIS FORM) Page 3 of 11 TO BE FILLED BY TREATING DOCTOR/HOSPITAL A: Name of the treating Doctor: B: Contact number: C: Nature of Illness/Disease with presenting complaint: ________ _ _ _ _ _ _ _ _ _ D: Relevant Critical Findings: E: Duration of the present ailment Days Date of First consultation: DD/MM/YYYY I. II. Past history of present ailment, if any _________ _ _ _ _ _ _ _ F: Provisional diagnosis: 1. ICD IO code G: Proposed line of treatment: i. ii. iii. IV. V. Medical Management Surgical Management Intensive care Investigation Non-allopathic treatment ( ) ( ) ( ) ( ) ( ) H: If investigation and/or Medical Management, provide details _______ _ _ _ _ _ _ _ 1. Route of Drug Administration _ _ _________ _ _ _ _ _ _ _ _ I: If surgical, name of surgery 1. ICD IO PCS code J: If other treatment, provide details K: How did injury occur L: In case of accident Is it RTA: Date oflnjury: Report to Police FIR 0 l!Yes g No (~M/YY OYes ONo I. 11. Ill. IV. V. VI. Injury /Disease caused due to substance abuse/alcohol consumption Test conducted to establish this (if yes, attach report) L_JYes LJ No CJ Yes D No m. In case of Maternity I. expected date of Delivery DD/MM/YYYY Page 4 of 11 DETAILS OF PATIENT ADMITTED A. Date of admission B. Time of admission C. Is this an emergency/planned hospitalization event: D. Mandatory Past History of any chronic illness 1. Diabetes 11. Heart disease 111. Hypertension iv. Hyperlipidemias v. Osteoarthritis v1. Asthma/CO PD/ Bronchitis v11. Cancer v111. Alcohol/Drug abuse 1x. Any HIV/ or STD Related ailment x. Any other ailment, give details E. Expected number of Days/stay in hospital F. Days in ICU G. Room Type H. Per day room rent+nursing and service charges+ patients diet I. Expected cost of investigation + diagnostic J. ICU charges K. OT charges L. Professional fees Surgeon + Anesthetist Fees + consultation Charges: (DD/MM/YYYY) ( HH: MM) Emergency D Planned D If yes (Since month/year) Days ______ Days M. Medicines+ Consumables + Cost of Implants (if applicable please specify) N. Other hospital expenses if any 0. All-inclusive package charges if any applicable P. Sum Total expected cost of hospitalization ---- ------- Page 5 of 11 DECLARATION (Please read very carefully) We confirm having read understood and agreed to the Declarations of this form a. Name of the treating doctor b. Qualification: c. Registration number with State code ________________________ _ Hospital Seal Patient/Insured ame and Sign (Must include Hospital ID) Page 6 of 11 DECLARATION BY THE PATIENT I REPRESENTATIVE a. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the lnsurerrf.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge. b. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy. c. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the lnsurerrf.P.A not governed by the terms and conditions of the policy will be paid by me. d. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the Insurer / T.P.A e. I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital will be of a particular quality or standard. f. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited. g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA. h. "I/We authorize Insurance CompanyrfPA to contact me/us through mobi le/email for any update on this claim". a. b. C. d. e. f. a) Patient's / Insured's Name: __________________________ _ b) Contact number: e-mail Id (optional) ______ _ d) Patient's/ lnsured's Signature: Date: ________ _ Time: _______ __ _ HOSPITAL DECLARATION We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization. All valid original documents duly countersigned by the insured I patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge. We agree that TPA / Insurance Company will not be liable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents. The patient declaration has been signed by the patient or by his representative in our presence. We agr_e~ _to provide clarifications for the queries raised regarding this hospitalization and we take the sole respons1b1hty for any delay in offering clarifications. We will abide by the terms and conditions agreed in the MOU. Page 7 of 11