About Paramount Health Services (TPA)

Transcription

1 INDEX 1. About Paramount Health Services (TPA) 2. Your Id Card How and when to use your card. 3. Call center General information and queries 4. How to intimate paramount 5. How to avail cashless services 6. Documents that you need to submit for a reimbursement claim. 7. FAQs About Paramount Health Services (TPA) Paramount Healthcare Services (TPA) Pvt. Ltd is a leading Third Party Administrator (TPA) in the Indian insurance industry. Operating since 2002, it is an ISO 9001:2008 Certified Company. It is promoted and run by medical professionals supported by personnel from diverse background like IT, Insurance & Customer Relations etc. Paramount Health Services operates in 27 states with over 1200 employees working to ensure outstanding service and support to over 2 crore customers including over 3000 corporate clients. Headquartered at Mumbai, Paramount has four regional offices at Delhi, Chennai, Kolkata, Bangalore and various other branch offices in major cities spread across the country. Today Paramount has become an inspirational story followed by others in India and is widely accepted as the best in this field. With our experience, we have made world of differences in many lives. Your ID card - How & when can you use your card? On the basis of details provided by the insurance company, Paramount issues a Health Card to each member covered under the policy. Your card is attached alongside this booklet. Please preserve this card and carry it with you at all times. It is not a credit or debit card but an Identity Card, which will identify you as the insured and will you give access to our network of Hospitals. Beside Physical Cards we have made provision to access Electronic Card (E-Cards) on our website as well as our mobile app. Provide your ID No. and the insurance company name whenever you call the Paramount help line no. Ensure you give your ID No. in all your correspondence.

2 Call Center Services- Paramount Call Center works 24 /7 with a dedicated helpline number that is provided to all our clients. At Paramount we believe a stitch in time saves nine, hence we strive to give correct and precise information to the client through our call centre. Sample queries handled by the call center are :- Cashless Procedure for cashless hospitalization. Confirmation of faxes received for cashless hospitalization. Replying to Cashless Status (Add. Info. Requirement, Denial of Cashless service, Issue of Authorization Letter) Reimbursement Receipt of Claim documents Availability of Data Claim status (Deficiency requirement, Repudiation of Claim, Clearance of claim) Reopening of claim. General Cards Status Provider Status (Network Hospital Status) Brief on Policy Details Sum Insured Details Website Details Claim Intimations What to do in case of Hospitalization - what is Intimation Claim Intimation is the process of notifying a claim to Paramount by specifying the timelines as well as the Hospital Name / Address / Contact number to which it should be notified. Insured has to notify / Intimate Paramount 48 Hours prior to any Planned Hospitalization. In case of Emergency Hospitalization, Insured has to notify / Intimate Paramount within 24 Hours of Hospitalization

3 Insured should notify the Hospitalization by calling at Paramount 24X7 Call Centre, Online Intimation on our website ( or on Jain Certificate is mandatory for all type of Claims without which no claims will be entertained. Insured need to submit Jain Certificate at the time of Cashless Hospitalization and even at the submitting Reimbursement Claim. How to avail cashless services Insured has to arrange for the Request for Hospitalisation (RAL) from Hospital, also known as Provider immediately after obtaining due details from the treating doctor in the preauthorization form prescribed by the Authority. The RAL shall be sent along with all the relevant details in the electronic form / Fax/ to the 24-hour authorization /cashless department of Paramount along with contact details of treating physician and the insured. In case of planned admission- the RAL shall reach the authorization department of Paramount prior to the expected date of admission. The RAL form shall be duly filled with clearly mentioning Yes or No and/or the details as required. The form shall not be sent with nil or blanks replies. Paramount guarantees payment only after receipt of RAL, Jain Certificate and the necessary medical details, subject to Policy Terms and Conditions. What will happen at Hospital Deposit In certain cases, a deposit may be required, payable to the hospital to cover non-medical expenses, for example Telephone / diet of attendant etc. Cashless Hospitalization Documents At the time of discharge insured needs to sign duly filled Claim form and necessary hospital documents. Hospital will submit all those documents to TPA for further processing of Claim. What happens at backend if Cashless is requested? On receipt of request for Cashless hospitalization at Paramount, Medical team at Paramount will determine whether the condition requiring admission and the treatment are covered by your health insurance policy. They will also check with all the other terms and conditions of your insurance policy. Non-medical expenses will not be payable.

4 In case coverage is available, Paramount will issue an approval to the hospital for a specified amount depending on the disease, treatment, how much you are insured for, etc. This is sent by fax and/or (if available). The approval is called a Preauthorization. This preauthorization entitles you to avail cashless facility at the hospital without paying for the medical expenses. Note: Further enhancement approvals may be issued on enhancement request, subject to terms and conditions of the policy. In case of any deficiency or query, an additional information letter will be sent to the Hospital. On receipt of the required and complete information, the request will be processed. Based on the processing of the claim, a denial or approval is executed. Please note- That denial of a preauthorization request is in no way to be construed as denial of treatment or denial of coverage. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement. At the time of discharge, please make sure that you check and sign the original bills and discharge summary. Please carry home a copy of the signed bill, discharge summary and all your investigation reports. This is for your reference and will also be useful during your future healthcare needs. What if the final bill is higher at the time of discharge? If treatment cost is increased during hospitalization, hospital may send request to Paramount for an additional sanction. Paramount will sanction additional cashless, subject to availability of balance Sum Insured and as per policy terms and conditions. In case of no further guarantee of payment from Paramount, Insured needs to settle the remaining amount prior to discharge. Please be aware of room rent eligibility. If admitted in a room higher then admissible ie. Room Rent Limit 2500/- Per day, as per the policy terms, there will be a deduction of a proportionate amount of the claim after excluding cost of medicines etc. Sample of Deduction Calculation Refer Last Page How to file a claim if insured gets hospitalized in non network hospital Reimbursement claims can be submitted to Paramount through courier, post or in person at any of our branches. Claim Documents should be sent to Paramount as per policy guidelines issued by insurer. Claim form can be collected from the nearest Divisional /

5 Branch Office of the Insurance Company / Paramount office or Claim forms can be downloaded from our website. Issuance of claim form does not mean guarantee of payment or any liability, under the policy on the part of the insurers. Documents that you need to submit for a hospitalization reimbursement claim are: 1. Jain Certificate is mandatory 2. Original completely dully filled Claim form 3. Covering letter stating your complete address, contact numbers and address (if available), along with Schedule of Expenses. 4. Copy of the Paramount ID card or current policy copy and previous years' policy copies (if any) 5. Original Discharge Card/ Summary 6. Original hospital final bill 7. Original numbered receipts for payments made to the hospital 8. Complete breakup of the hospital bill 9. All bills for investigations done with the respective reports 10. All bills for medicines supported by relevant prescriptions 11. Cancelled Cheque for quicker transfer of claim amount directly into your bank account through NEFT. Note: You are advised to keep Photo Copy of the entire set of claim documents submitted to us. FAQs Why are there deductions in my reimbursement claim? Charges for the certain facilities are not covered by insurance co. and those expenses are deducted from the reimbursement claims. What are these expenses that are not covered? The following few expenses are not reimbursable as per standard policy conditions. Telephone/Fax Food & Beverages for relatives Barber Non Medical expenses Diet charges whish are not part of the administered treatment etc.

6 "National Electronic Funds Transfer - NEFT Details By providing the bank account particulars (including the IFSC code of your bank) you are ensuring, quicker transfer of claim amount directly into your bank account. It is very important to note that the policyholder can benefit from the quicker electronic payment systems (RTGS/NEFT) only if they are able to furnish their bank account details accurately in their claim forms. Also arrange to send Cancelled Cheque for verification of NEFT Payment. When can my claim settlement get delayed? In case the documents are not submitted appropriately. In case the document are not submitted completely. In case Bank details are not provided. Deduction Calculation Example 1 Incremental Charges Calculation Sheet (Excluding Medicine, Consumble & non payable charges) Per Day Amt Room rent Caping as per policy per day Room rent Charges as per bill per day Particular Spent Amount Payble Amt Incremental Deduction Amt Room Charges ( For 1 Day) Surgeon Charges Operation Theatre Charges Anasthesia & Anasthesist Charges Doctor Visit Charges Investigation Charges Others Charges Medicines Charges Total Charges

7 Deduction Calculation Example 2 Incremental Charges Calculation Sheet (Excluding Medicine, Consumble & non payable charges) Per Day Amt Room rent Caping as per policy per day Room rent Charges as per bill per day Particular Spent Amount Payble Amt Incremental Deduction Amt Room Charges ( For 1 Day) Surgeon Charges Operation Theatre Charges Anasthesia & Anasthesist Charges Doctor Visit Charges Investigation Charges Others Charges Medicines Charges Total Charges Your are Link to Good Health Donate Organs save lives Cleanliness is next to Godliness Support Swach Bharat Abhiyan