This document provides guidance for filling out an insurance claim form. It outlines the various sections of the form, including details of the insured and hospitalization, diagnosis and treatment details, documents required, and declarations. Key sections include insured details, hospital and doctor information, diagnosis and treatment codes, pre-authorization, documents submitted, and declarations by insured and hospital.
Health plus claim is a part of life insurance. Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Plus, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and attached with all the necessary documents absence of which can lead to complication.
Claim form for Optima Senior is easily available on the website of Apollo Munich. With this provision, the process has been uncomplicated.
The policyholder need to provide basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Restore, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents absence of which can lead to complication.
Health plus claim is a part of life insurance. Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Plus, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and attached with all the necessary documents absence of which can lead to complication.
Claim form for Optima Senior is easily available on the website of Apollo Munich. With this provision, the process has been uncomplicated.
The policyholder need to provide basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Restore, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents absence of which can lead to complication.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. Easy Health Pre- Authorization form will seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents to avail the service.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Hospital treatment form is also a part of health insurance policies.These forms are also useful in case of medical insurance and to be filled in by the Hospital.If the treatment is from more than one hospital, forms from all the hospitals must be filled and submitted.
Optima Restore claim form seek information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form at Apollo Munich website, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Take a look at the check list of enclosures to be submitted with the claim form.
You can acquire the claim form for Optima Plus through Apollo Munich Health Insurance website. Here the buyer need to provide basic information like policy number, contact details, name of the policyholder, details of the insured, nature of disease or illness caused, nature of claim and list of enclosures to be attached with the form. The documents provided must be complete and genuine as per the claim. It is to be filled with due care and after proper understanding. Any dishonest information provided can affect the coverage offered by the plan.
With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Health plus claim intimation form is for Health Insurance Policies (HCB & MSB Claims).Form must be completed & signed by Policy Holder / Principal Insured only and submitted to the TPA.
Complete Procedure using attached template.1. For new patients, cr.docxbrownliecarmella
Complete Procedure using attached template.
1. For new patients, create the patient account by entering the following information on a patient account ledger card:
a. Patient’s full name, address, and at least two contact phone numbers
b. Date of birth
c. Health insurance information, including the subscriber numbers, group number, and effective date
d. Subscriber’s name and date of birth (if the subscriber is not the patient)
e. Employer’s name and contact information.
2. For returning patients, review the account record to see whether a balance is due. If there is a balance, bring this to the patient’s attention when he or she comes for the appointment (include this in the ledger summary referenced below). Respectfully explain that the provider would appreciate a payment on the previous balance before he or she can care for the patient. Then complete the encounter form, including all procedures and the associated fee schedule.
3. Total all the charges on the encounter form for the services rendered.
4. Then subtract the copayment made from the total charges. The previous balance, if any, is added to this new total.
5. Please write a brief collaborative report (150-200 words) on each ledger.
...
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. Easy Health Pre- Authorization form will seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents to avail the service.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Hospital treatment form is also a part of health insurance policies.These forms are also useful in case of medical insurance and to be filled in by the Hospital.If the treatment is from more than one hospital, forms from all the hospitals must be filled and submitted.
Optima Restore claim form seek information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form at Apollo Munich website, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Take a look at the check list of enclosures to be submitted with the claim form.
You can acquire the claim form for Optima Plus through Apollo Munich Health Insurance website. Here the buyer need to provide basic information like policy number, contact details, name of the policyholder, details of the insured, nature of disease or illness caused, nature of claim and list of enclosures to be attached with the form. The documents provided must be complete and genuine as per the claim. It is to be filled with due care and after proper understanding. Any dishonest information provided can affect the coverage offered by the plan.
With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Health plus claim intimation form is for Health Insurance Policies (HCB & MSB Claims).Form must be completed & signed by Policy Holder / Principal Insured only and submitted to the TPA.
Complete Procedure using attached template.1. For new patients, cr.docxbrownliecarmella
Complete Procedure using attached template.
1. For new patients, create the patient account by entering the following information on a patient account ledger card:
a. Patient’s full name, address, and at least two contact phone numbers
b. Date of birth
c. Health insurance information, including the subscriber numbers, group number, and effective date
d. Subscriber’s name and date of birth (if the subscriber is not the patient)
e. Employer’s name and contact information.
2. For returning patients, review the account record to see whether a balance is due. If there is a balance, bring this to the patient’s attention when he or she comes for the appointment (include this in the ledger summary referenced below). Respectfully explain that the provider would appreciate a payment on the previous balance before he or she can care for the patient. Then complete the encounter form, including all procedures and the associated fee schedule.
3. Total all the charges on the encounter form for the services rendered.
4. Then subtract the copayment made from the total charges. The previous balance, if any, is added to this new total.
5. Please write a brief collaborative report (150-200 words) on each ledger.
...
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Trauma Outpatient Center is a comprehensive facility dedicated to addressing mental health challenges and providing medication-assisted treatment. We offer a diverse range of services aimed at assisting individuals in overcoming addiction, mental health disorders, and related obstacles. Our team consists of seasoned professionals who are both experienced and compassionate, committed to delivering the highest standard of care to our clients. By utilizing evidence-based treatment methods, we strive to help our clients achieve their goals and lead healthier, more fulfilling lives.
Our mission is to provide a safe and supportive environment where our clients can receive the highest quality of care. We are dedicated to assisting our clients in reaching their objectives and improving their overall well-being. We prioritize our clients' needs and individualize treatment plans to ensure they receive tailored care. Our approach is rooted in evidence-based practices proven effective in treating addiction and mental health disorders.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
India Diagnostic Labs Market: Dynamics, Key Players, and Industry Projections...Kumar Satyam
According to the TechSci Research report titled “India Diagnostic Labs Market Industry Size, Share, Trends, Competition, Opportunity, and Forecast, 2019-2029,” the India Diagnostic Labs Market was valued at USD 16,471.21 million in 2023 and is projected to grow at an impressive compound annual growth rate (CAGR) of 11.55% through 2029. This significant growth can be attributed to various factors, including collaborations and partnerships among leading companies, the expansion of diagnostic chains, and increasing accessibility to diagnostic services across the country. This comprehensive report delves into the market dynamics, recent trends, drivers, competitive landscape, and benefits of the research report, providing a detailed analysis of the India Diagnostic Labs Market.
Collaborations and Partnerships
Collaborations and partnerships among leading companies play a pivotal role in driving the growth of the India Diagnostic Labs Market. These strategic alliances allow companies to merge their expertise, strengthen their market positions, and offer innovative solutions. By combining resources, companies can enhance their research and development capabilities, expand their product portfolios, and improve their distribution networks. These collaborations also facilitate the sharing of technological advancements and best practices, contributing to the overall growth of the market.
Expansion of Diagnostic Chains
The expansion of diagnostic chains is a driving force behind the growing demand for diagnostic lab services. Diagnostic chains often establish multiple laboratories and diagnostic centers in various cities and regions, including urban and rural areas. This expanded network makes diagnostic services more accessible to a larger portion of the population, addressing healthcare disparities and reaching underserved populations. The presence of diagnostic chain facilities in multiple locations within a city or region provides convenience for patients, reducing travel time and effort. A broader network of labs often leads to reduced waiting times for appointments and sample collection, ensuring that patients receive timely and efficient diagnostic services.
Rising Prevalence of Chronic Diseases
The increasing prevalence of chronic diseases is a significant driver for the demand for diagnostic lab services. Chronic conditions such as diabetes, cardiovascular diseases, and cancer require regular monitoring and diagnostic testing for effective management. The rise in chronic diseases necessitates the use of advanced diagnostic tools and technologies, driving the growth of the diagnostic labs market. Additionally, early diagnosis and timely intervention are crucial for managing chronic diseases, further boosting the demand for diagnostic lab services.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
For those battling kidney disease and exploring treatment options, understanding when to consider a kidney transplant is crucial. This guide aims to provide valuable insights into the circumstances under which a kidney transplant at the renowned Hiranandani Hospital may be the most appropriate course of action. By addressing the key indicators and factors involved, we hope to empower patients and their families to make informed decisions about their kidney care journey.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
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Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
1. CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Claims Processing Centre: Hari Nivas Towers, Second Floor,
Toll Free Ph no: 1800 200 5544 Toll Free Fax no: 1800 425 2200
e-mail:Customercare@cholams.murugappa.com;
www.cholainsurance.com
k) Type of hospitalization: Emergency / Planned
Deluxe Room Others
Filled claim form duly signed
Copy of the claim intimation
Final Hospital Bill with detailed break-up
Hospital bill payment receipt
Detailed hospital discharge summary
Pharmacy / medical bills which supporting doctor
prescription
Investigation / lab reports supporting the diagnosis.
Operation theatre notes for surgical cases
Invoice / sticker for the implants used in the treatment.
External Aids vendors supported by the proper
prescription from Doctor.
Home Hospitalization treatment - Certificate from
treating doctor specifying reasons for Home
Hospitalization
Obstetric History for maternity claims (GPAL Status)
Copy of MLC / FIR / in case of road traffic accidents
(RTA)
AML documents (Proof of Identity with photo, Address
proof) for above 1 lac claims
Note : Please enclose a cancelled cheque / copy of the same, NEFT cannot be facilitated without the cancelled cheque / copy
Membership Number:
vi. External aids:
vii. OPD dental: viii.OPD:
x. Minor accompaniment daily cash:
ix.Eye check up cost:
Suite
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
xi.
2. DECLARATION BY THE INSURED:
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance com pany, to seek necessary
medical information / documents from any hospital / Medical 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.
Date: D D M M Y Y Place: Signature of the Insured
GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
b) SI. No/ Certificate No.
Enter the social insurance number or the certificate number of
social health insurance scheme
As allotted by the organization
c) Company TPA ID No. Enter the TPA ID No
License number as allotted by IRDA and
printed in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health
Insurance?
Indicate whether currently covered by another Mediclaim /
Health Insurance
Tick Yes or No
b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format
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 Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last 4 years Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim/ Health
Insurance?
Indicate whether previously covered by another Mediclaim /
Health Insurance
Tick Yes or No
f) Company Name Enter the full name of the insurance company Name of the organization in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date 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 Enter the phone number of patient Include STD code with telephone number
i) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease first detected/ Date of
Delivery
Enter the relevant date Use dd-mm-yy format
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
d) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax department
b) Account Number Enter the bank account number As allotted by the bank
c) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full
d) Cheque/ DD payable details
Enter the name of the beneficiary the cheque/ DD should be
made out to
Name of the individual/ organization in full
e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION
H
3. ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
4. GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network nospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code
Enter the registration number of the doctor along with the state
code
As allocated by the Medical Council of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B – DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of Discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) Type of Admission Indicate type of admission of patient Tick the right option
j) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis
Enter the ICD 10 Code and description of the primary
diagnosis
Standard Format and Open text
Additional Diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Standard Format and Open text
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
c) Present Ailment is a Complication of PED
Indicate whether present ailment is a complication of some pre-
existing disease
Tick Yes or No
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained, give
reason
Enter reason for not obtaining pre-authorization number Open text
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption,
test conducted to establish this
Indicate whether test conducted Tick Yes or No
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text
SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. Enter the registration number of patient As allocated by the Hospital
d) PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient Beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL