What documents are required for a cashless claim?

1. At the time of pre-authorization/initial approval:

The specific documents required for pre-authorization or initial approval of a cashless claim can vary depending on the insurance company and the type of insurance policy. However, some common documents typically requested during the pre-authorization process include:

1. Claim Form:  The insured individual needs to fill out and submit the claim form, providing essential details such as policy number, name of the insured, contact information, and the treating doctor & billing department will fill a brief description of the medical condition or treatment, estimate, expected discharge date,
2. ID Proof: A valid government-issued identification document, such as a passport/DL/Aadhar/Voter ID, is often required to verify the identity of the insured. The patient name and age should be matched with policy detail, kindly contact us immediately if there is any mismatch on your name age between your ID proof and E-card/Policy copy.
3. E-card/ Policy Copy (For Individual Policy): The physical or digital copy of the insurance policy card or certificate should be provided as proof of insurance coverage. If there is a waiting period for diseases for which the patient was admitted, the insurance company may be asked for the previous policy details.
4. Medical Prescription: A written prescription from the treating doctor outlining the recommended treatment or medical procedure is typically necessary.
5. Medical Reports: Relevant medical reports related to the diagnosis, medical history, and current condition may be required to support the claim.
6. Medical Investigation Reports: If any diagnostic tests or investigations were conducted, reports such as X-rays, MRI scans, blood tests, etc., should be submitted. The supporting investigation reports to the main diagnosis are mandatory.
7. Doctor’s Note or Letter: A letter from the treating doctor explaining the medical necessity of the proposed treatment and the expected duration of hospitalization, if applicable.
8. Cost Estimate: In some cases, an estimate of the expected treatment cost from the hospital is required.
9. Previous Treatment Records: For follow-up treatments or chronic conditions, previous treatment records and treatment history may be requested.
10. Any Additional Information: Depending on the specific circumstances, the insurance provider may request additional documents or information related to the claim.

2. At the time of midterm enhancement.

 In case of prolonged stay and the preauthorization approval is not sufficient to carry out further treatment; the hospital may be approach for the midterm enhancement approvals with the following documents:

1. An application letter from the hospital for the midterm enhancement approval.
2. A detailed report from the treating doctor explaining the reasons for the extended treatment and why it is necessary for the patient’s health and recovery. This should include a comprehensive explanation of the medical condition, the progression of the illness, and the proposed treatment plan.
3. Copy of ICP paper till date.
4. Current running bill with revised estimate.
5. All investigation report carried out till date.

3. At the time of final/discharge approval

• Enhancement request with justification for enhancement of the amount – quote the Preliminary authorization Approval Letter number

• Report on any changes in the Final Diagnosis/ change in the treatment administered/ history of the ailment/s
• Detailed Discharge Summary/Daycare Summary indicating
  • The Primary Diagnosis for which treatment has been administered – its history
  • Secondary Diagnosis for which (possibly) treatment has been administered – their history
  • Co-morbidities – their history
  • Symptoms/ complaints on admission
  • Tests conducted
  • Treatment administered
  • Discharge advice
  • GPLA Status in case of any pregnancy related claims.
  • ICP paper and temperature chart if any.

• Death Summary (instead of discharge summary) where the patient has passed away during hospitalization.
• Investigation Reports – for all tests conducted – excluding the reports already sent for preliminary authorization
• Histopathology Report – wherever possible
• Operation Theatre Notes – where surgery is performed
• MLC  report/ FIR for accident cases – if not submitted at the time of Preliminary Authorisation
• Sticker for the implants used and invoice of the implants.
• Hospital Main Bill duly signed by the patient
• Detailed break-up bill for the hospital Main Bill – duly signed by the patient.