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TRAINING SESSION
HEALTH INSURANCE CLAIMS ADJUDICATION
CONTINUES LEARNING FROM MISTAKES
ADAPTING TO PREVAILING MARKET
TRENDS,PRACTICES
SELECT THE CORRECT RIDERS AS PER POLICY
 MATERNITY
 HOSPITALIZATION
 OUT-PATIENT
 MAJOR MEDICAL
 CRITICAL ILLNESS
 CORPORATE POOL
PRE & POST CLAIMS
PRE & POST SHOULD BE MENTIONED ON FILE
BE WELL VERSED WITH THE CLIENT POLICY
 EXCLUSIONS
 PRE EXISTING COVERAGE
 PRE & POST HOSPITALIZATION
 OUT- PATIENT
 WAIVER OF BENCH MARKING IN RE IMBURSEMENT CASES
 PRE & POST NATAL COVERAGE
 POLICY PERIOD
PROPERLY STUDY EVALUATE AND REVIEW THE CASE
BEFORE DISCUSSING WITH MANAGER
IN SUSPICIOUS CASES MATCH THE TREATMENT
TICKET WITH THE PHARMACY INVOICES
PRESCRIBED MEDICATION TERMINOLOGY
 OD ONCE DAILY
 BD TWICE A DAY
 TDS THREE TIMES A DAY
 QID FOUR TIMES A DAY
ICU AND ROOM STAY: MATCH THE TOTAL NUMBER
OF DAYS AGAINST THE CHARGED ROOM RENT / ICU
STAY
IF A REQUIREMENT RAISED BY EVALUATION DOCTOR
IS NOT FULFILLED DUE TO ANY REASON THEN
WAIVER SHOULD BE AUTHORIZED FROM
CONCERNED DOCTOR / MANAGER
IN CASE OF ANY OBJECTION/COMMENT BY
SURVEILLANCE DO NOT PROCEED UNTIL
OBJECTION/COMMENT IS WAIVED OFF
BENCH MARKING GUIDELINES
 PANEL HOSPITAL OF SIMILAR STANDARD IN SAME DISTRICT /
ADJACENT DISTRICT
 MENTION THE NAME OF BENCH MARK HOSPITAL ON THE FILE
 TABULATE THE WORKING ON THE PHYSICAL FILE/ EXCEL FOR
FUTURE REFERENCE
BASIC BENCH MARKING SCALES
 SURGEON FEE
 ANESTHESIA FEE 1/3 OF SURGEON FEE
 OT FEE 1/3 OF SURGEON FEE
 PHARMACY MEDICINE / LABS
 ROOM RENT
Presentation1

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Presentation1

  • 1.
  • 2. TRAINING SESSION HEALTH INSURANCE CLAIMS ADJUDICATION
  • 4. ADAPTING TO PREVAILING MARKET TRENDS,PRACTICES
  • 5. SELECT THE CORRECT RIDERS AS PER POLICY  MATERNITY  HOSPITALIZATION  OUT-PATIENT  MAJOR MEDICAL  CRITICAL ILLNESS  CORPORATE POOL
  • 6. PRE & POST CLAIMS PRE & POST SHOULD BE MENTIONED ON FILE
  • 7. BE WELL VERSED WITH THE CLIENT POLICY  EXCLUSIONS  PRE EXISTING COVERAGE  PRE & POST HOSPITALIZATION  OUT- PATIENT  WAIVER OF BENCH MARKING IN RE IMBURSEMENT CASES  PRE & POST NATAL COVERAGE  POLICY PERIOD
  • 8. PROPERLY STUDY EVALUATE AND REVIEW THE CASE BEFORE DISCUSSING WITH MANAGER
  • 9. IN SUSPICIOUS CASES MATCH THE TREATMENT TICKET WITH THE PHARMACY INVOICES
  • 10. PRESCRIBED MEDICATION TERMINOLOGY  OD ONCE DAILY  BD TWICE A DAY  TDS THREE TIMES A DAY  QID FOUR TIMES A DAY
  • 11. ICU AND ROOM STAY: MATCH THE TOTAL NUMBER OF DAYS AGAINST THE CHARGED ROOM RENT / ICU STAY
  • 12. IF A REQUIREMENT RAISED BY EVALUATION DOCTOR IS NOT FULFILLED DUE TO ANY REASON THEN WAIVER SHOULD BE AUTHORIZED FROM CONCERNED DOCTOR / MANAGER
  • 13. IN CASE OF ANY OBJECTION/COMMENT BY SURVEILLANCE DO NOT PROCEED UNTIL OBJECTION/COMMENT IS WAIVED OFF
  • 14. BENCH MARKING GUIDELINES  PANEL HOSPITAL OF SIMILAR STANDARD IN SAME DISTRICT / ADJACENT DISTRICT  MENTION THE NAME OF BENCH MARK HOSPITAL ON THE FILE  TABULATE THE WORKING ON THE PHYSICAL FILE/ EXCEL FOR FUTURE REFERENCE
  • 15. BASIC BENCH MARKING SCALES  SURGEON FEE  ANESTHESIA FEE 1/3 OF SURGEON FEE  OT FEE 1/3 OF SURGEON FEE  PHARMACY MEDICINE / LABS  ROOM RENT