What is TPA?

Third Party Administration (TPA) is a service given to a Mediclaim policyholder by providing cashless facility for all hospitalisations that come under the scope of his/her Mediclaim policy

What are the benefits of TPA to a policyholder?

The policy holder will have full freedom to choose the hospitals from our empanelled network and utilise the services as per his choice · For every hospitalisation, the policyholder will be well aware whether the treatment he is to undergo is covered under his policy or not. If covered, then he can seek cashless facility without having to pay a single rupee at any of Heritage Health Services Network hospitals. · During the time of Emergency Hospitalisation, the policyholder or relative can flash the Photo ID Card of the policyholder and gain admission into any of our network hospitals. · Priority treatment at hospital is given without any payment to be made at the any time of admission. So also at the time of discharge, no payments to be made. Thus, a complete CASHLESS TREATMENT. Thus, the Individual does not run around for arranging cash for paying for the hospital expenses.

What are the facilities offered by a TPA?

i. A 24 X 7 assistance to all policy holders through our toll free number 1800 345 3477

ii. Assuring a Priority and Quality Treatment at Network Hospitals.

iii. Speedy claim settlement in case the policy holder has been treated from a non-network hospital

Issuance of Cards / Guide books

One of the job's of the TPA's is to maintain databases of policyholders and issue them identity cards with unique identification numbers which will be used to handle all the post policy issues including claim settlements.This identity card along with the guide book containg the list of network hospital is deliverd to the policyholders after receiving their policycopies from their respective Insurance company.

Cashless Claims

What is Cashless Service?

Till recently the Mediclaim policyholders had to pay the hospital for treatment and then send the bills to the insurance company for reimbursement. Henceforth, the insured will not have to pay the network hospitals after undergoing treatment. He will have to sign the bills and we will pay the hospital for the treatment undertaken by the insured (subject to Policy Terms, exclusions and Conditions).

How does Cashless Service work?

Each person covered under the Policy will be issued an identity card. Whenever there is a need for hospitalisation the policyholder should obtain an Authorization Letter from Heritage Health Services . The authorization letter will indicate the name of the insured/patient, the name of the hospital where treatment is required, the nature of illness/ disease for which treatment is required and the monetary limit above which the insured/ patient will have to pay. The policyholder will have to submit this authorization letter along with the identity card given by Heritage Health Services to the admission counter in the hospital. The hospital will then start treatment.

How does one avail Cashless Service?

The policyholder is required to fill the request for authorization or pre- authorization letter and send it to the nearest Heritage Health Services office mentioned in the booklet/ web site. Additional copies of the Pre-Authorization letter can be obtained from any of the Heritage Health Services offices given or you could get the same at the hospital. Heritage Health Services will scrutinize the request for authorization letter and send an authorization letter or Denial letter.

What are the Document to be submitted with the Pre- Authorization form?

The Pre-authorisation form has to be accompanied by
> The photocopy of the HHSPL card
> Policy Copy
> First Prescription
> Any other relevent Invertigation reports if required.

How does one get Reimbursement for pre and post hospitalisation expenses?

The Mediclaim Policy allows reimbursement of medical expenses incurred towards the ailment/ disease for which hospitalisation was necessitated prior to hospitalisation and up to a certain number of days after discharge.

This is subject to the limits as described in the policy. The medical expenses incurred prior to Hospitalisation are called pre- hospitalisation expenses and those incurred subsequent to discharge as post Hospitalisation expenses.

Send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to the nearest Heritage Health Services Office. Heritage Health Services will scrutinize the claim and settle the bills subject to the policy conditions. The bills must be sent to Heritage Health Services within 7 days from the date of Receipt of Fitness Certificate or within 60 day of discharge from hospital.

Reimbursement Claims

What is Reimbursement Claims?

Cashless Hospitalisation is available only in Network Hospitals. While it's recommended that you choose a network hospital you are at liberty to choose a non-network hospital also. In case you avail of treatment in a Non Network hospital, HHSPL will reimburse you the amount of bills subject to the policy taken by the policyholder.

How does one file Reimbursement Claims?

The Policy Holders attention is drawn to the definition of Hospital in the Mediclaim policy. HHSPL should be contacted within 7 days from the time of admission with details of HHSPL card number, nature of illness, name & address of the Hospital/ Nursing Home/ Clinic, attending Doctor, Bed Number etc. The claim form can be collected from the nearest branch of the Insurance company / HHSPL office. This claim form must be filled fully and sent to the nearest HHSPL office along with the following documents in original.

What are the documents required to lodge under the medical reimbursement scheme.

>Copy of Member ID card with the member’s details.
>Copy of the policy papers if any.
>Claim form properly filled
>Original detailed discharge summary.
>Original investigation reports
>Original Hospital Bill-consolidated and with detail breakup with the patients signature on it.
>Pharmacy bills and breakup.
>Prescriptions .

Note: member needs to retain a photocopy of all the documents he is submitting for future reference.

Are there chances of 'claim rejection'?

Yes, in case of discepancy in documents or in case of non compliance with the policy conditions the claim may be rejected,