Contents:
1. About Third Party Administration Services
2. Services Offered by I-Care
3. Claim Process – Cashless – (Emergency / Planned) Hospitalization
4. Reimbursement Claim Process
5. Reimbursement of Pre & Post Hospitalization (Supplementary Claim)
6. Forms: Pre –
Claim Form
Authorization Form
Customer Feedback Form
7. I-Care Offices / Contact Details
8. List of Network Service Provider (NSP)
About Third Party Administrator Services:
Third Party Adminstrator as a concept was introduced by Insurance Regulatory and Development Authority with the aim of providing fair and fast claim settlement to the customers in the fast growing health insurance industry.
A TPA acts as a bridge that connects insurer, provider (hospital) and the consumer by facilitating claim settlement in tune with the policy terms and conditions as well as arranging cashless hospitalisations through agreements with providers.
Cashless facility has been increasingly utilised by the customers as it obviates the need for worrying about making payment to the hospital, instead of focusing on getting back to shape.
The TPA also would have entered into agreements to treat the members through preferred admission process. This again ensures there is less to be concerned about in the process of hospitalisation for the member.
As a professional claim manager, the TPA is able to bring in efficiency into the system, reduce claim processing effort to the insurance company and indirectly reducing the cost of health insurance to the customer.
The TPA achieves this by having professional claim processors lead by medical practitioners and customer service people who liaise with the customers through the claim process. Though the TPAs have medically qualified people, it is not customary for them to advice the customer on the line of treatment, which is best left to a medical professional who can examine the member physically.
The member also has the choice the hospitals to get treated though cashless facility will be available only from the empanelled network. It is also advisable for the customer to read through his insurance policy just to make sure that there are no restrictions on using a particular system of medicine or a provider as far as the insurance is concerned.
Technology plays an increasing role as the TPAs in India have to manage enormous amount of customer information and provide access to the various stakeholders. Members of a TPA usually carry an ID card that provides identification and the membership number. This card is useful enough to carry for the member.
TPAs have served the health insurance industry in the past seven years by substantially improving customer service and professiobalising claim management. With a TPA behind you, your mind can leave behind anxiety of what if…
Services Offered By I-Care:
As a licensed Third Party Administrator for Health for your insurance company I-Care will provide its insured members with the following services :
I. Bar coded PVC cards for each member of the family
II. Option of E-Card for your family member
III. Web login for access to information
IV. Cashless Hospitalization at all our NSP and PSP
V. Claim settlement
VI. 24*7 call centre support
VII. Online support
Claim Process: Cashless Hospitalization happens under two circumstances – Planned and Emergency. Pre – authorization of the estimated hospital expense is a must to avail this facility.
Planned hospitalization :
In the case of planned hospitalization or admission, you would have first consulted a doctor who in turn would have advised you on the probable date or time of hospitalization. In such a case, you are required to apply for a pre – authorization to I-Care at least 3- 4 days prior to the date of hospitalization. We suggest you call I-Care immediately to intimate and take advice on the cashless process.
i. Your Consultant doctor Advices you for admission or hospitalization.
ii. You can choose a network hospital or a nursing home from I-Care website, Member Manual or you can also call the call centre and ask for the names of NSP.
iii. Get the pre – authorization form filled by the NSP at least 3 – 4 days in advance and insure that it is faxed or emailed to I-Care.
iv. Once I-Care receives the pre – auth request from the NSP it will process the request and either approve or deny the pre – auth request depending on the policy term and condition of the insurer.
v. The authorization letter which can be a approval or a denial will be sent to the NSP via fax or email and a SMS or email will be sent to the Insured informing him the status of the pre – auth request.
Emergency hospitalization :
In case of emergency hospitalization or admission, the member covered needs to approach any of our NSP (hospital or nursing home) of your choice and present your I-Care id card to the help desk at the NSP. The help desk at the NSP will get the pre – auth form filled and faxed or emailed to I-Care on a fast track basis.
For a cashless treatment it is mandatory for the NSP to have an approval from I-Care. In case you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit.
Once the approval is received by the NSP from I-Care the NSP will return the cash deposit made by you.
Note: Denial of cashless treatment does not in any way mean denial of treatment. You can apply for reimbursement of your claim once you get discharged from the hospital / nursing home. The claim shall be dealt with as per the policy term and condition of the insurer.
Reimbursement Claim Process :
In case of admission in a non network hospital (emergency/planned) the following process has to be followed:
Planned hospitalization:
i. Intimate I-Care about your hospitalization thru fax or email well in advance.
ii. Get admitted in the hospital “please make sure that the hospital or the nursing home where you are getting yourself or your family member treated meets the insurer’s criteria”.
iii. At the time of discharge please collect all the documents in original eg. discharge summery, final bill, prescription, medicine bills, all the test reports and films.
iv. Lodge your claim with I-Care within 7 days of your discharge.
Emergency hospitalization:
i. Get yourself admitted in the nearest hospital / nursing home of your choice.
ii. Intimate I-Care about your hospitalization as soon as possible.
iii. At the time of discharge please collect all the documents in original eg. discharge summery, final bill, prescription, medicine bills, all the test reports and films.
iv. Lodge your claim with I-Care within 7 days of your discharge.
Reimbursement of Pre and Post hospitalization expenses :
Most of the health insurance policies allow reimbursement of medical expenses incurred towards the ailment or disease for which
hospitalization was required for a certain number of days prior to the hospitalization and discharge of hospitalization.
If your policy covers
the pre and post hospitalization expenses then please fill in the claim form and submit all the test reports, medical bill along with the
prescription and any other document along with the copy of the discharge summary to I-Care. I-Care shall process and settle your claim
as per the policy terms and condition of the insurer.
Without Prejudice
REMBURSMENT CLAIM FORM
Issuance of this form does not
amount to admission of any liability under the claim on the part of the insurers
Patient Information Policy Holder information
Card ID Name
Name Address
age
Relationship to Insured Insurer
Contact no Policy no
Member covered since Period to
Hospital / Provider name
Provider code
Information on Illness / Injury and Treatment
Ailment / injury for which the member was treated
Date of admission Time of
admission AM / PM
Date of discharge Time of discharge AM / PM
Principal Diagnosis
Other Diagnosis
Medico legal Yes / No Road
Accident Yes / No
Disease code (ICD) First occurrence (Patient known to have this condition since)
Line of Treatment (Procedure done)
Procedure code (CPT)
Treating doctor details Name: Phone no:
Qualification: Regn no:
Treatment cost details:
S No Service description
Amount charged Discount Net amount Patient paid amount Balance due Remarks
1 Room Charges
2 ICU/CCU/Nursery Charges
3
Doctor's Fee
4 Lab Investigation
5 Radiology
6 Other Investigation
7 Special Procedure
8 Pharmacy Service
9 OT/ Labour Room Service
10 Others (Pl specify)
Total amount claimed
UNDERTAKING BY THE PATIENT:
I hereby warrant the truth of the foregoing particulars in
every respect& I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to claim
reimbursement of the expenses shall be absolutely forfeited.
I also authorize the hospital/provider to submit the attested Indoor Case
Papers (Case sheets) and any other documents/information related to my treatment to I-Care if asked for.
I further declare that in respect
of the above treatment no benefits are admissible under any other Medical Scheme or Insurance.
Provider Representative Policy Holder/Patient
Name:
1) Name:
2) Date:
3) Date:
4) Signature:
Signature: Enclosures to be attached (Please Tick)
I) If Surgery is involved, Surgery bills with Receipt
II) Medicine bills with prescriptions
III) OT Pharmacy Bills
Iv) Others
V) Discharge Summary
VI) Hospitalization Bills with breakups
Customer feedback form |
To |
|
|
|
|
|
The COO, I-Care |
|
|
|
|
Please find my feedback on the claim services of I-Care enclosed |
|
Name: |
|
I-Care ID: |
|
Provider used: |
|
Date: |
|
|
|
|
Please tick what is applicable |
Cashless authorisation |
I forwarded the cashless request through |
Provider |
I-Care Customer care |
Remarks |
Cashless authorisation |
I was guided through the process for cashless |
Yes |
No |
|
Cashless authorisation |
Some one explained the pre-authorisation form to me. |
Yes |
No |
|
Cashless authorisation |
I was told about the expenses that do not form part of the policy. |
Yes |
No |
|
Cashless authorisation |
I was asked all the clarifications at one go |
Yes |
No |
|
Cashless authorisation |
I was informed through sms / e-mail of the authorisation / queries |
Yes |
No |
|
Cashless authorisation |
I was told the reason, if the authorisation was less than the required amount. |
Yes |
No |
|
Cashless authorisation |
I-Care was easy to approach when I needed additional authorisation. |
Yes |
No |
|
Claim settlement |
I was received courteously |
Yes |
No |
|
Claim settlement |
I was provided an acknowledgement for my documents |
Yes |
No |
|
Claim settlement |
I was told about the further process that follows my submission of documents |
Yes |
No |
|
Claim settlement |
I was contacted for any additional information through letter / e-mail / sms. |
Yes |
No |
|
Claim settlement |
I was asked all additional information in one go. |
Yes |
No |
|
Claim settlement |
I was informed of the settlement through sms / e-mail / letter. |
Yes |
No |
|
Claim settlement |
Where there were non-admissible charges, I was told of the reason. |
Yes |
No |
|
Claim settlement |
The claim was settled within my time expectations |
Yes |
No |
|
Enrolment |
I received my enrolment kit within my time expectation. |
Yes |
No |
|
Enrolment |
The details in the kit about me were correct |
Yes |
No |
|
Enrolment |
Where I required a change in my details, the same was done in time. |
Yes |
No |
|
Enrolment |
Issues like courier non-delivery, etc were handled to my satisfaction. |
Yes |
No |
|
Enrolment |
The Member Manual was useful to me |
Yes |
No |
|
Website |
The I-Care website (www.icaretpa.com) was useful to me. |
Yes |
No |
|
Website |
All the details I required about my membership were available to me on the website. |
Yes |
No |
|
Website |
Details about me were correct. |
Yes |
No |
|
Website |
The contents about healthcare and health insurance are useful to me. |
Yes |
No |
|
Website |
The web pages are easy to navigate. |
Yes |
No |
|
Customer care |
I was able to reach the customer care easily |
Yes |
No |
|
Customer care |
I was able to reach the customer care quickly. |
Yes |
No |
|
Customer care |
I was received courteously on the phone |
Yes |
No |
|
Customer care |
My issue was resolved in the first call to my satisfaction. |
Yes |
No |
|
Customer care |
Customer care helped me reach the right person, where it was required. |
Yes |
No |
|
Customer care |
Customer care people called me back in time as promised. |
Yes |
No |
|
Customer care |
Customer care helped me resolved my issue to my satisfaction. |
Yes |
No |
|
I-Care Office and Contact Detail:
24*7 Call Centre :
Help line – 1860 425 3232
Toll free – 1800 425 3232 “for emergency hospitalization”
Fax - 1860 425 4242
URL - www.icaretpa.com
Head Office :
56, Syndicate Bank Officer’s Colony
West Marredpally, Secunderabad.
Pin – 500 026, Andhra Pradesh
Phone line - 1860 425 3232
Fax - 1860 425 4242
Regional Office South :
Banglaore – No.1/2, G.S Park,
1 st Floor, Infantry Park Road
Tasker Town, Shivajinagar
Bangalore – 560 052
Phone No. - 1860 425 3232
Fax - 1860 425 4242
List of Network Service Provider
Note:
- For the latest list of network service provider please visit our website www.icaretpa.com or call our call center. The name of the service providers mentioned in the Member Manual is just indicative and is subject to changes without notice.
- All the claim forms are available on our website under downloads.
Issued By:
M/S. I-Care Health Management & TPA Services Pvt. Ltd.
56, Syndicate Bank Officers Colony
West Marredpally, Secunderabad
Andhra Pradesh – 500 026
Talk to Us: 1860 425 3232
Fax Us: 1860 425 4242
Toll Free: 1800 425 3232
Web Access: www.icaretpa.com
|
