LIST OF OCUENTS REQUIRE FOR SETTLEENT OF HOSPITALISATION CLAIS 1. FOR CLAIING HOSPITALISATION EXPENSES A CLAI FOR PART A: UL COPLETE B THE INSURE ON THE PRESCRIBE FORAT - ORIGINAL B CLAI FOR PART B: UL COPLETE AN SIGNE B THE HOSPITAL AUTHORITIES - ORIGINAL C AISSION NOTES CERTIFIE COP TPA I CAR XEROX COP E F G H I J K L N O P Q R S T U V W X AN OTHER I PROOF LIKE VOTER I/ L/ PASSPORT ETC - COP ARESS PROOF - COP REFERRAL LETTER, IF AN, TO HOSPITAL CERTIFIE COP ETAILE ISCHARGE SUAR - ORIGINAL EATH SUAR (INSTEA OF ischarge Summary) IF PATIENT HAS PASSE AWA URING HOSPITALISATION - ORIGINAL INVESTIGATION REPORTS - IN ORIGINAL FOR INVESTIGATIONS ONE URING HOSPITALISATION HISTOPATHOLOG REPORT, IF AN, IN ORIGINAL CERTIFIE COP OF OPERATION THEATRE (OT) NOTES WHERE SURGER IS PERFORE LC REPORT/ FIR FOR ACCIENT CASES CERTIFIE COP STICKER FOR THE IPLANTS USE - ORIGINAL SUPPPORTING INVOICE FOR THE IPLANTS USE CERTIFIE COP HOSPITAL AIN BILL - ORIGINAL BREAK-UP BILL FOR THE HOSPITAL AIN BILL - ORIGINAL ETAILE BILL FOR THE NON-AISSIBLE AOUNTS COLLECTE FRO THE PATIENT RECEIPT FOR THE AOUNT COLLECTE FRO THE PATIENT RECEIPT FOR THE CO-PA COLLECTE FRO THE PATIENT COP OF THE PRE-AUTH ENIE LETTER, IF AN, FOR CASHLESS ENIE CONFIRATION FRO THE HOSPITAL FOR NON-UTILISATION OF CASHLESS FACILIT, IF CASHLESS SANCTIONE PRESCRIPTIONS FOR EICINES PURCHASE URING HOSPITALISATION PHARAC BILLS IN ORIGINAL FOR EICINES PURCHASE URING HOSPITALISATION LIST OF BILLS SUBITTE WITH THE AOUNT UNER EACH BILL OCUENTS FOR NATIONAL ELECTRONIC FUN TRANSFER (NEFT) Z a. NEFT FORAT GIVING ETAILS OF BANK ACCOUNT CLAI AOUNT TO BE TRANSFERRE b. A COP OF THE PAGE OF BANK PASS BOOK CONTAINING A/C NUBER & NAE/ ARESS OF A/C HOLER. AA AB c. A CANCELLE CHEQUE FOR THE ABOVE ACCOUNT IN TO WHICH CLAI AOUNT HAS TO BE TRANSFERRE COVERING LETTER STATING OUR COPLETE CURRENT ARESS, CONTACT NUBER AN THE LIST OF OCUENTS ATTACHE AN OTHER OCUENT THAT THE CLAI PROCESSING TEA/ TPA REQUESTS 2. FOR CLAIING PRE-HOSPITALISATION EXPENSES a b c d e f g h CLAI FOR - PART A UL COPLETE AN SIGNE OP CONSULTATION PAPER, IF AN ORIGINAL CONSULTATION BILL/ CASH RECEIPT, IF AN PRESCRIPTION FOR EICINES PURCHASE PRIOR TO HOSPITALISATION PHARAC CASH BILLS FOR EICINES PURCHASE PRIOR TO HOSPITALISATION INVESTIGATION REPORTS - IN ORIGINAL FOR INVESTIGATIONS ONE PRIOR TO AISION, IF AN CASH BILLS FOR THE INVESTIGATIONS ONE PRIOR TO HOSPITALISATION REFERENCE LETTER FOR INVESTIGATION CONUCTE PRIOR TO HOSPITALISATION Page1
i j OCUENTS FOR NATIONAL ELECTRONIC FUN TRANSFER (NEFT) AS IN ITE 1 - Z ABOVE COVERING LETTER STATING OUR COPLETE CURRENT ARESS, CONTACT NUBER & LIST OF OCUENTS ATTACHE 3. FOR CLAIING POST-HOSPITALISATION EXPENSES a b c d e f g h i j CLAI FOR PART A UL COPLETE AN SIGNE OP CONSULTATION PAPER, IF AN ORIGINAL CONSULTATION BILL/ CASH RECEIPT, IF AN PRESCRIPTION FOR EICINES PURCHASE - POST-ISCHARGE PHARAC BILLS FOR EICINES PURCHASE - POST-ISCHARGE INVESTIGATION REPORTS - IN ORIGINAL FOR INVESTIGATIONS ONE - POST-ISCHARGE, IF AN CASH BILLS FOR THE INVESTIGATIONS ONE - POST-ISCHARGE REFERENCE LETTER FOR INVESTIGATION CONUCTE - POST-ISCHARGE OCUENTS FOR NATIONAL ELECTRONIC FUN TRANSFER (NEFT) AS IN ITE 1 - Z ABOVE COVERING LETTER STATING OUR COPLETE CURRENT ARESS, CONTACT NUBER AN THE LIST OF OCUENTS ATTACHE 4. FOR HOSPITALS CLAIING CASHLESS HOSPIALISATION EXPENSES APPROVE A B C E F G H I J K L N O P Q R S T U V W X Z CLAI FOR PART A: UL COPLETE B THE INSURE ON THE PRESCRIBE FORAT - ORIGINAL CLAI FOR PART B: UL COPLETE AN SIGNE B THE HOSPITAL AUTHORITIES - ORIGINAL AISSION NOTES CERTIFIE COP TPA I CAR XEROX COP AN OTHER I PROOF LIKE VOTER I/ L/ PASSPORT ETC - COP ARESS PROOF - COP PRE-AUTHORISATION REQUEST IN ORIGINAL UL SIGNE B THE INSURE AN THE HOSPITAL PRE-AUTHORISATION APPROVAL LETTER COP REFERRAL LETTER, IF AN, TO HOSPITAL CERTIFIE COP ETAILE ISCHARGE SUAR - ORIGINAL EATH SUAR (INSTEA OF ischarge Summary) IN CASE THE PATIENT HAS PASSE AWA URING HOSPITALISATION - ORIGINAL INVESTIGATION REPORTS - IN ORIGINAL FOR INVESTIGATIONS ONE URING HOSPITALISATION HISTOPATHOLOG REPORT, IF AN, IN ORIGINAL CERTIFIE COP OF OPERATION THEATRE (OT) NOTES WHERE SURGER IS PERFORE LC REPORT/ FIR FOR ACCIENT CASES CERTIFIE COP STICKER FOR THE IPLANTS USE - ORIGINAL SUPPPORTING INVOICE FOR THE IPLANTS USE CERTIFIE COP HOSPITAL AIN BILL - ORIGINAL BREAK-UP BILL FOR THE HOSPITAL AIN BILL - ORIGINAL ETAILE BILL FOR THE NON-AISSIBLE AOUNTS COLLECTE FRO THE PATIENT RECEIPT FOR THE AOUNT COLLECTE FRO THE PATIENT FOR THE NON-AISSIBLE AOUNTS RECEIPT FOR THE CO-PA COLLECTE FRO THE PATIENT PRESCRIPTIONS FOR EICINES PURCHASE URING HOSPITALISATION PHARAC BILLS IN ORIGINAL FOR EICINES PURCHASE URING HOSPITALISATION LIST OF BILLS SUBITTE WITH THE AOUNT UNER EACH BILL AN OTHER OCUENT THAT THE CLAI PROCESSING TEA/ TPA REQUESTS NOTE: (1) OU SHOUL SUBIT THE ABOVE OCUENTS ALONG WITH A COVERING LETTER (2) IF OU ARE SUBITTING PRE &/OR POST- HOSPITALISATION CLAIS SEPARATEL OU SHOUL SUBIT THE CLAI FOR UL COPLETE (3) ALSO SUBIT THIS CHECKLIST Page2
Annexure I Vidal Health TPA Pvt. Ltd IBA Hospitalisation Claim Reimbursement Statement (The Federal Bank Ltd.) Name of the Bank Policy No Name of the Insured Vidal I Card No Employee Id Cadre Name of the Claimant Relation to Claimant Nature of Illness ate of Submission Sl No Bill ate Bill No/escription Amount Claimed Remarks Signature of the Insured: Total Amount Claimed: Note: This form should be attached along with Signed Claim Format A.
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:
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) 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
ELECTRONIC CLEARING SERVICE (CREIT CLEARING) ANATE FOR For Claim under Policy No 1. A CARHOLER S NAE (B) ARESS (C) TELEPHONE / OBILE No: () E-AIL I: 2. TTK I No 3. PARTICULARS OF BANK ACCOUNT A. BANK NAE B. BRANCH NAE C. ARESS. 9 IGIT COE NUBER OF THE BANK & BRANCH APPEARING ON THE ICR CHEQUE ISSUE B THE BANK E. ACCOUNT TPE (SAVINGS ACCOUNT/ CURRENT ACCOUNT) F. ACCOUNT NUBER (AS APPEARING ON THE CHEQUE BOOK) G. BANK ACCOUNT HOLER NAE 4. ATE OF EFFECT: 5. IFSC COE (INIAN FINANCIAL SSTE COE) INFORATION FOR PAENT THROUGH RTGS OR NEFT 6. NEFT COE (NATIONAL ELECTRONIC FUNS TRANSFER COE) By submission of the above, I authorise /s Vidal Health TPA Private Ltd (formerly known as TTK Healthcare TPA Pvt Ltd) / the Insurance Company to settle the claim under reference through direct payment by ECS. I hereby declare & confirm that the particulars given above are correct and complete. I agree that I shall not hold the TPA/ Insurance Company responsible for delay or non-receipt of payment for any reason whatsoever after issue of instructions for transfer of payment by Insurer/ TPA based on the above. ate: Place: Signature of the Insured