M/S.NATCO PHARMA LTD.

Transcription

1 /S.NATCO PHARA LT. UNITE INIA INSURANCE COPAN LIITE Policy No : /28/15/P Policy Start ate-21/01/2016 Policy End ate 20/01/2017 2/18/ India Health Care Services ( TPA ) Pvt Ltd

2 Contents of Presentation Parties to Group edi-claim Policy. Functions of India Scope of ediclaim Terms & Condition for /S.Natco Pharma Ltd Permanent policy exclusion How to avail Cashless Facility How to avail Re-imbursement Facility Checklist - ocuments to be submitted for Re-imbursement Network of Hospitals for Cashless Website Access Navigation for Individual Employee Aneroid obile App Navigation HAWK APP Toll free No. and mail ids India Health Care Services (TPA) Pvt. Ltd. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

3 Group ediclaim Policy Insurance Company United India Insurance Company Limited. Corporate Group ediclaim Natco Pharma Ltd. Third Party Administrators India Healthcare Services (TPA) Pvt. Ltd 2/18/ India Health Care Services ( TPA ) Pvt Ltd

4 India Healthcare Services Pvt Ltd India Healthcare Service (TPA) Pvt. Ltd. was formed in November 2000, a licensed third Party Administrator (License No. 005) and were very soon a leading company in the insurance sector. The success of the Company has been built year on year by an ability to anticipate the future requirements of the Health insurance industry. Awarded : 2013 The Indian Insurance Awards: Best TPA Award 2014 The Indian Insurance Awards: Best TPA Award th Asia Insurance Industry Awards: Service Provider of the ear 2015 The Indian Insurance Awards: Innovative TPA of the ear 2/18/ India Health Care Services ( TPA ) Pvt Ltd

5 What would you look for in a service provider INIA AT A GLANCE Founded in November 2000 IRA License no 005 Headquartered in Pune, aharashtra One of the leading companies in the Health Insurance sector of India The Largest TPA in India by Revenue, Lives Serviced, Claims Settled & Headcount FE 2013 Projected : 1st TPA to breach 100 Cr Revenue ark Pan India footprint with 115 Servicing locations In-House eveloped Software deployed with 54 member strong team Employees strong consisting of 500+ edico s on pay roll as full-time employees with core team of BBS, /S Specialists & Ch Surgeons ISO, CRISIL & QCI certified 24x7 Customer Care and Support and Website Services Net work Hospitals Transparent communication Reliable processing TATs Error free processing Response timeframes & quality Accessibility Reach Claim Cost Control Coordination with Insurance company & Broker Exceptional calls to be taken Hassle free hospitalization Policy understanding Strategic Guidance Value adds 2/18/2016 India Health Care Services ( TPA ) Pvt Ltd 5

6 Functions of India (TPA) To work as a Nodal agency between Insurance Company, Natco Pharma Ltd, and the Hospitals. To issue I Cards to all the members covered under the policy. To administer Cashless Facility in network hospitals & reimbursement claims settlement as per the policy terms and conditions. To negotiate & procure comprehensive schedule of charges from empanelled hospitals. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

7 Scope of ediclaim COVERAGE - Any Insured Person who shall contract any disease /illness or sustain any bodily injury through accident and upon the advice of a duly qualified doctor for Hospitalisation in any Hospital in India. ROO RENT ELIGILIBIT Includes Room, boarding and nursing expenses Normal Room ax Limit 1.5% Per day. ICU Room ax Limit 3% Per day. (This also includes Nursing Care, RO & O Charges, IV Fluids/ Blood Transfusion Charges /Injection Administration Charges and similar expenses) HOSPITALISATION - eans admission in any Hospital/Nursing Home in India upon the written advice of a edical Practitioner for a minimum period of 24 consecutive hours. PRE HOSPITALISATION medical charges up to 30 days period immediately before the Insured s admission to hospital for that illness or injury. POST HOSPITALISATION medical charges up to 60 days period immediately after the Insured s discharge from the hospital for that illness or injury. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

8 Terms & Conditions for Natco Pharma Policy. POLIC COVERS: 1+5 (Self, Spouse, 2 ependent Childrens and 2 parents or Inlaws) SU INSURE Rs:200000/- per family. PRE-EXISTING ISEASES COVERAGE: Waived Off 4.1: Pre-Existing Illness/ Ailments are waived Off. 4.2: 30 ays lock in period waived off for any claim. 4.3: 1r/2r/3r/4r Exclusion waiting period waived Off. ABULANCE CHARGES:1% of SI 2/18/ India Health Care Services ( TPA ) Pvt Ltd

9 Terms & Conditions for Natco Pharma Ltd. Cataract, Hernia, Hysterctomy Limits: Actual expenses incurred or 25% of the Sum insured whichever is less. ajor Surgeries: Actual expenses incurred or 70% of the sum insured whichever is less. Claim intimation to be given within 48 Hrs. from date of admission Claim submission to be done within 15 days from date of discharge. Cheque in Favour of: Reimbursement claim payment should be in favour of Employee. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

10 POLIC EXCLUSIONS The Insurance Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of: 1. Any Out Patient Charges/ OP Treatment. 2. The cost of spectacles, contact lenses and hearing aids, external durable items. 3. ental treatment or surgery of any kind unless requiring hospitalization. 4. Convalescence, general debility, a run-down condition or rest cure, external congenital disease, defects or anomalies, sterility, venereal disease or intentional self injury. 5. All expenses arising out of any condition directly or indirectly caused by or associated with Human T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphadenopathy Associated Virus (LAV) or the utants erivative or variations of eficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIS. (Information available in the Policy Summary booklet) 6. Sex change or any treatment which results from, or is in any way related to, sex change. Hormone replacement therapy. 7. The treatment of psychiatric, mental or nervous conditions and insanity. 8. Any cosmetic, plastic surgery, aesthetic or related treatment of any description, whether or not for psychological reasons, unless medically necessary as a result of an accident. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

11 POLIC EXCLUSIONS 9. Any treatment received in convalescent homes, convalescent hospitals, health - hydros, Nature Cure clinics or similar establishments. 10. Any stay in hospital for any domestic reason or where there is no active, regular treatment by a specialist. 11. Any treatment received outside India. 12. Complication of surgery, therapy or treatment administered on the Insured Person which is not prescribed or required by a Registered edical Practitioner/ Registered edical Institution in their professional capacity. 13. Taking of drugs unless it is taken on proper medical advice and is not for the treatment of drug addiction. 14. Any fertility, sub-fertility or assisted conception operation. 15. Any person whilst engaging in speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides and ropes, pot holing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports and activities and similar hazards. 16. Any person whilst engaging in aviation, whilst mounting into or demounting from or traveling in any aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world*. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

12 Claim Process CASHLESS Cashless Facility is available at Network Hospitals, provided the purpose of Hospitalisation is within the scope of cover and adherence to protocol. The patient need to bring ediclaim I card along with any valid Photo I card (e.g.-voter I, Passport, PAN card, riving Licence, School or College I card etc.), during admission to Hospitalisation. Hospital will send RAL & related documents to TPA ( India) TPA will examine the documents, if the ailment is covered under the policy, they will ACCOR a Cashless facility to the member. If Cashless is accorded, TPA will inform the member and the hospital on the same & will send a letter of approval (Authorisation Letter) to Hospital, for CASHLESS facility. Similar Procedure is followed after ischarge is confirmed. In case of further clarifications, India will contact employee/hr. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

13 Claim Process REIBURSEENT In case of a medical claim where the member has already paid or intends to pay the hospital bill, then the following process should be followed Intimate to TPA 48 hrs. prior to admission Pay the Hospital bill Complete the claim form. Attach all the original documents & submit the same to India Helpdesk / respective HR Person. The complete set is forwarded to TPA ( India) within 15 days from the ate of ischarge from the Hospital. In case of further clarifications, India will contact employee/hr TPA will lodge a claim with the Insurance Company after verifying the documents. If the claim is payable, payment will be forwarded to the respective Employee Account. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

14 Checklist - ocuments to be submitted for Re-imbursement 1. uly filled & signed Claim form by the employee with the seal & signature of the concerned authority in the organization. 2. Photocopy of Cashless card. 3. Original ischarge card / ischarge summary. 4. Original Hospital bill with the seal & signature of the Hospital along with the Bill No. Printed 5. etailed Hospital bill break-up for the expenses incurred. 6. All original prescriptions & consultation papers of the octor. 7. All original edical bills with the name of the Patient duly endorsed by the treating octor. 8. All original cash paid receipts supporting the bills in the name of patient vide receipt No:s. 9. All original edical reports certified by the octor (Pathology, X-Ray, CT-Scan, ECG, RI, etc.) 10. Summary of all Expenses. 11. edico Legal Certificate (LC) / FIR in case of accident cases. 12. edico Legal Certificate (LC) & FIR both are mandatory in case of road traffic accident. 13. All Indoor Case Papers (ICP). 14. Cancelled cheque of the Employee along with Employee Name printed on Cheque leaf or Bank Pass Book. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

15 Website Access - Online Visit us at Click on Login -- y Account Corporate Employee and Click 2/18/ India Health Care Services ( TPA ) Pvt Ltd

16 Login to your account Please provide your complete policy number / I as on policy schedule 2/18/2016 2/18/ I Confidential Proprietary Information 16 India Health Care Services ( TPA ) Pvt Ltd

17 Welcome to primary information screen Click on E card to download E card or on claims to see details of claims. 2/18/2016 2/18/ I Confidential Proprietary Information 17 India Health Care Services ( TPA ) Pvt Ltd

18 E - Cards Print E card as per your convenience if you require to give it to someone and during claims submission. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

19 Android Phones obile App 2/18/ India Health Care Services ( TPA ) Pvt Ltd

20 First Screen of the App Click/Tap Corporate Policy Holder 2/18/ India Health Care Services ( TPA ) Pvt Ltd

21 Enter the Valid obile Number, Verification code shall be sent to the obile number entered. This is one time registration process. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

22 Below details can be validated or obtained from employee individual login: 1. E-Cards of Self & ependents. 2. Claims Status Cashless & Reimbursement. 3. Policy Features and eligibility Criteria. 4. Network List of Hospitals for Cashless Facility across Pan India. 5. Various forms available online 2/18/ India Health Care Services ( TPA ) Pvt Ltd

23 Provider Network Our Network of Hospitals across Pan India Chandigarh 11 Himachal Pradesh Haryana 100 elhi Punjab Uttarakhand 10 Uttar Pradesh HOSPITALS EPANELE & GROWING Bihar Rajasthan 7 adhya Pradesh Jharkhand Gujarat Orissa aman & iu 2 aharashtra Chattisgarh Assam West Bengal 4 eghalaya Andhra Pradesh Goa Karnataka 261 *Visit website for latest list Kerala Tamil Nadu 2/18/ India Health Care Services ( TPA ) Pvt Ltd

24 Toll free No. and E-ail ids India Health Care Services (TPA) Pvt Ltd. Employee may contact Toll Free & UAN Numbers Cashless Hospitalization: The Request for authorization(cashless) form can be sent with the help of network Hospital to the following No. or mail id. 1. Toll free Fax No authorisation@mdindia.com Customer Care: The Employee can contact the Customer Care on :- 1.Toll free No or customercare@mdindia.com 3. Online x 7 for 365 days at your services Toll free numbers for cashless services and customer queries. Supported with edical Query Assistance round the clock. 2/18/ India Health Care Services ( TPA ) Pvt Ltd

25 Point Of Contacts and Escalation atrix India Health Care Services (TPA) Pvt Ltd. Contact etails: s. Navara Renuka Landline : / hyderabadcorp@mdindia.com Escalation Level Name Contact No ail I Level1 s. Navara Renuka hyderabadcorp@mdindia.com Level2 s. Sangeetha Tammali stammali@mdindia.com Level3 r.somasekhar Reddy sreddy@mdindia.com Level4 r.anand Rao asagiri adasagari@mdindia.com; 2/18/ India Health Care Services ( TPA ) Pvt Ltd

26 India Health Care Services ( TPA ) Pvt Ltd India Health Care Services ( TPA ) Pvt Ltd 14 Jun 2015

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29 CLAI FOR - PART A' to 'CLAI FOR FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT - PART A TO BE FILLE B THE INSURE (To be Filled in block letters) The issue of this Form is not to be taken as an admission of liablity ETAILS OF PRIAR INSURE: a) Policy No.: b) Sl. No/ Certificate no. c) Company/ TPA I No: d) Name: S U R N A E F I R S T N A E I L E N A E e) Address: City: State: Pin Code Phone No: I: ETAILS OF INSURANCE HISTOR: a) Currently covered by any other ediclaim / Health Insurance: es No b) ate of commencement of first Insurance without break: c) If yes, company name: Policy No. Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract? es No ate: iagnosis: e) Previously covered by any other ediclaim /Health insurance : : es No SECTION A SECTION B f) If yes, company name: ETAILS OF INSURE PERSON HOSPITALIZE: : a) Name: S U R N A E F I R S T N A E I L E N A E b) Gender ale Female c) Age years onths d) ate of Birth e) Relationship to Primary insured: Self Spouse Child Father other Other (Please Specify) f) Occupation ETAILS OF HOSPITALIZATION: : ETAILS OF CLAI: ETAILS OF BILLS ENCLOSE: Sl. No. Bill No. ate Issued by Towards Amount (Rs) City: Service g) Address (if diffrent from above) : Pin Code Phone No: I: a) Name of Hospital where Admited: ETAILS OF PRIAR INSURE S BANK ACCOUNT:: Self Employed b) Room Category occupied: ay care Home aker Student Retired State: Other (Please Specify) Single occupancy Twin sharing 3 or more beds per room c) Hospitalization due to: Injury Illness aternity d) ate of injury / ate isease first detected /ate of elivery: e) ate of Admission: f) Time H H H g) ate of ischarge: h) Time: H H : H I) If injury give cause: Self inflicted Road Traffic Accident ii) Reported to Police a) etails of the Treatment expenses claimed I. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Charges: Rs. Rs. Rs. iii. LC Report & Police FIR attached Substance Abuse / Alcohol Consumption es No ii. Hospitalization expenses iv. Health-Check up cost: vi. Others (code): j) System of edicine: vii. Pre -hospitalization period: days viii. Post -hospitalization period: days b) Claim for omiciliary Hospitalization: es No c) etails of Lump sum / cash benefit claimed: i. Hospital aily cash: Rs. iii. Critical Illness benefit: Rs. v. Pre/Post hospitalization Lump sum benefit: Rs. a) PAN: c) Bank Name and Branch: d) Cheque / Payable details: Total (If yes, provide details in annexure) ii. Surgical Cash: iv. Convalescence: vi. Others: Total b) Account Number: Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Nos Nos e) IFSC Code: I) If edico legal es No Claim ocuments Submitted - Check List: Claim form duly signed Copy of the claim intimation, if any Hospital ain Bill Hospital Break-up Bill Hospital Bill Payment Receipt Hospital ischarge Summary Pharmacy Bill Operation Theater Notes ECG octor s request for investigation Investigation Reports (Including CT / RI / USG / HPE) octor s Prescriptions Others SECTION C SECTION SECTION E SECTION F SECTION G (IPORTANT: PLEASE TURN OVER)

30 ECLARATION B THE INSURE: I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA / Insurance Company, to seek necessary medical information / documents from any hospital / edical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any. SECTION H ate Place: Signature of the Insured GUIANCE FOR FILLING CLAI FOR - PART A (To be filled in by the insured) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF PRIAR INSURE a) Policy No. Enter the policy number As allotted by the Insurance Company b) Sl. No/ Certificate No. Enter the social Insurance number or the certificate number of social health insurance scheme As allotted by the oraganization c) Company TPA I No. Enter the TPA I No. Licence number as allotted by IRA and printed in TPA documents. d) Name Enter the full name of the policyholder Surname, First name, iddle name e) Address a) Currently covered by any other ediclaim / Health Insurance? Enter the full postal address SECTION B -ETAILS OF INSURANCE HISTOR Indicate whether currently covered by another ediclaim / Health Insurance Include Street, City and Pin code Tick es or No b) ate of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat c) Company Name Enter the full name of the Insurance Company Name of the organization in full Policy No. Enter the policy number As allotted by the Insurance Company Sum insured d) Have you been Hospitalized in the last four years since Inception of the contract? Enter the total sum insured as per the policy Indicate whether hospitalized in the last four years In rupees Tick es or No ate Enter the date of Hospitalization Use mm-yy format iagnosis Enter the diagnosis details Open Text e) Previously covered by any other ediclaim / Health Insurance? Indicate whether previously covered by another mediclaim / Health Insurance Tick es or No f) Company Name Enter the full name of the Insurance Company Name of the organization in full SECTION C -ETAILS OF INSURE PERSON HOSPITALIZE a) Name Enter the full name of the patient Surname, First name, iddle name b) Gender Indicate Gender of the patient Tick ale or Female c) Age Enter age of the patient Number of years and months d) ate of Birth Enter ate of Birth of patient Use dd-mm-yy format e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specify f) Occupation indicate occupation of patient Tick the right option. If others, please specify. g) Address Enter the full postal address Include Street, City and Pin code h) Phone No 1) I Enter the phone number of patient Enter address of patient SECTION - ETAILS OF HOSPITALIZATION Include ST code with telephone number Complete address a) Name of Hospital where admited Enter the name of hospital Name of hospital in full b) Room category occupied c) Hospitalization due to d) ate of injury/ate isease first detected / ate of elivery e) ate of admission f) Time g) ate of discharge h) Time I) If injury give cause If edico legal Reported to Police LC Report & Police FIR attached j) System of edicene a) etails of Treatment Expences b) Claim for omiciliary Hospitalization c) etails of Lump sum/ Cash benifit claimed d) Claim documents Submitted-Check List Indicate which bills are enclosed with the amount in rupees a) PAN b) Account Number c) Bank Name and Branch c) Cheque/ payable details c) IFSC Code indicate the room category occupied indicate reason of hospitalization Enter the relevant date Enter date of admission Enter time of admission Enter date of discharge Enter time of discharge indicate cause of injury indicate whether injury is medico legal indicate whether police report was filed indicate whether LC report and Police FIR attached Enter the system of medicine followed in treating the patient SECTION E - ETAILS OF CLAI Enter the amount claimed as treatment expences indicate whether claim is for domiciliary hospitalization Enter the amount claimed as lump sum / cash benefit indicate which supporting documents are submitted SECTION F - ETAILS OF BILLS ENCLOSE SECTION G - ETAILS OF PRIAR INSURE s BANK ACCOUNT Enter the permanent account number Enter the Bank account number Enter the Bank name along with the branch Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. Enter the name of the beneficiary the cheque / should be made out to Enter the IFSC code of the Bank branch SECTION H - ECLARATION B THE INSURE Tick the right option Tick the right option Use dd-mm-yy format Use dd-mm-yy format Use hh-mm- format Use dd-mm-yy format Use hh-mm- format Tick the right option Tick es or No Tick es or No Tick es or No Open Text In rupees (o not enter paise values) Tick es or No In rupees (o not enter paise values) Tick the right option As allotted by the Income Tax epartment As allotted by the Bank Name of the Bank in full Name of the individual / organization in full IFSC code of the Bank branch in full

31 ETAILS OF HOSPITAL CLAI FOR - PART B TO BE FILLE IN B THE HOSPITAL The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request form in lieu of PART A (To be Filled in block letters) a) Name of the hospital: a) Hospital I: c) Name of the treating doctor: e) Qualification: ETAILS OF THE PATIENT AITTE a) Name of the Patient: f) ate of Admission: j) Type of Admission: Emergency Planned ay Care c) Type of Hospital: Network : Non Network : (if non network fill section E) f) Registration No. with State Code: g) Phone No. aternity k) If aternity I) Status at time of discharge: ischarge to home ischarge to another hospital eceased ETAILS OF AILENT IAGNOSE (PRIAR) a) IC 10 Codes I. Primary iagnosis ii. Additional iagnosis: iii. Co-morbidities: iv. Co-morbidities: c) Pre-authorization obtained: es e) If authorization by network hospital not obtained, give reason: escription b) No vi. If not reported to police give reason: d) Pre-authorization Number: h) ate of ischarge: i) ate of elivery: i. Procedure 1: ii. Procedure 2: iii. Procedure 3: iv. etails of Procedure: m) Total claimed amount IC 10 PCS f) Hospitalization due to injury: es No I. If es, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this: v. FIR No. CLAI OCUENTS SUBITTE - CHECK LIST Claim Form duly signed Original Pre-authorization request Copy of the Pre-authorization approval letter Copy of Photo I Card of patient Verified by hospital Hospital ischarge summary Operation Theatre Notes Hospital main bill Hospital break-up bill AITIONAL ETAILS IN CASE OF NON NETWORK HOSPITAL a) Address of the Hospital d) Hospital PAN: iii. Others: ECLARATION B THE HOSPITAL es No (If es, attach reports) Investigation reports iii. If edico legal: CT/R/USG/HPE investigation reports octor s reference slip for investigation ECG Pharmacy bills LC reports & Police FIR es No Original death summary from hospital where applicable Any other, please specify (ONL FILL IN CASE OF NON-NETWORK HOSPITAL) ii) Gravida Status: : escription iv. Reported to Police (PLEASE REA VER CAREFULL) We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited. ate: City: S U R N A E F I R S T N A E I L E N A E S U R N A E F I R S T N A E I L E N A E b) IP Registration Number: c) Gender: ale Female d) Age: ears onths e) ate of birth: g) Time: H H Pin Code: b) Phone No. c) Registration No. with State Code: State: e) Number of inpatient beds f) Facilities available in the hospital i. OT es No ii. ICU es No H H es No SECTION A SECTION B SECTION C SECTION SECTION E SECTION F Place: Signature and Seal of the Hospital Authority:

32 GUIANCE FOR FILLING CLAI FOR - PART B (To be filled in by the hospital) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF HOSPITAL a) Name of the hospital: Enter the name of hospital Name of the hospital in full b) Hospital I c) Type of Hospital c) Name of treating doctor e) Qualification f) Registration No. with State Code g) Phone No. a) Name of Patient b) IP registration Number c) Gender d) Age e) ate of Birth f) ate of Admission g) Time h) ate of ischarge i) Time j) Type of Admission k) If aternity ate of elivery Gravida Status l) Status at time of discharge ) Total claimed amount a) IC 10 Code Primary iagnosis Additional iagnosis Co-morbidities b) IC 10 PCS Procedure 1 Procedure 2 Procedure 3 etails of Procedure c) Pre-authorization obtained d) Pre-authorization Number Enter I number of hospital Indicate whether in network or non network hospital Enter the name of the treating doctor Enter the qualification of the treating doctor Enter the registration number of the doctor along with the state code Enter the phone number of doctor SECTION B - ETAILS OF THE PATIENT AITTE Enter the name of patient Enter insurance provider registration number Indicate Gender of the patient Enter age of the patient Enter date of birth Enter date of admission Enter Time of admission Enter date of ischarge Enter time of ischarge Indicate type of admission of patient Enter ate of elivery if maternity Enter Gravida status if maternity Indicate status of patient at time of discharge Indicate the total claimed amount SECTION C - ETAILS OF AILENT IAGNOSE (PRIAR) Enter the IC 10 Code and description of the primary diagnosis Enter the IC 10 Code and description of the additional diagnosis Enter the IC 10 Code and description of the Co-morbidities Enter the IC 10 Code and description of the first procedure Enter the IC 10 Code and description of the second procedure Enter the IC 10 Code and description of the third procedure Enter the details of the procedure Indicate whether pre-authorization obtained Enter pre-authorization number As allocated by the TPA Tick the right option Name of doctor in full Abbreviations of educational qualifications As allocated by the edical Council of India Include ST code with telephone number Name of patient in full As allotted by the insurance provider Tick ale or Female Number of years and months Use dd-mm-yy format Use dd-mm-yy format Use hh:mm format Use dd-mm-yy format Use hh:mm format Tick the right option Use dd-mm-yy format Use standard format Tick the right option In rupees (o not enter paise values) Standard Format and Open text Standard Format and Open text Standard Format and Open text Standard Format and Open text Standard Format and Open text Standard Format and Open text Open text Tick es or No As allotted by TPA e) If authorization by network hospital not obtained, give reason Enter reason for not obtaining pre-authorization number Open text f) Hospitalization due to injury Cause If injury due to substance abuse/alcohol consumption test conducted to establish this edico Legal Reported to Police FIR No. If not reported to police, give reason Indicate which supporting documents are submitted a) Address b) Phone No. c) Registration No. with State Code d) Hospital PAN e) Number of Inpatient beds f) Facilities available in the hospital Indicate if hospitalization is due to injury Indicate cause of injury Indicate whether test conducted Indicate whether injury is medico legal Indicate whether police report was filed Enter first information report number Enter reason for not reporting to police SECTION - CLAI OCUENTS SUBITTE-CHECK LIST SECTION E - ETAILS IN CASE OF NON NETWORK HOSPITAL Enter the full postal address Enter the phone number of hospital Enter the registration number of the Hospital obtained from local body like City Corporation / unicipality Enter the permanent account number Enter the number of inpatient beds Indicate facilities available in the hospital SECTION F - ECLARATION B THE HOSPITAL Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stamp Tick es or No Tick the right option Tick es or No Tick es or No Tick es or No As issued by police authrities Open text Include Street, City and Pin Code Include ST code with telephone number As allocated by the City Corporation / unicipality As allocated by the Income Tax epartment igits Tick the right option. If others, please specify