An Overview of the Cashless Claim Process in Health Insurance

An Overview of the Cashless Claim Process in Health Insurance

In recent years, more and more insurers have started providing cashless hospitalization as a part of their health insurance plans. This is a uniquely beneficial feature as it enables the policyholder to receive treatment from network hospitals without having to pay large amounts of cash up front. The insurer handles the payment with the hospital while the policyholder has to pay only for the deductibles. Cashless hospitalization is beneficial, especially for emergency situations. Regardless, one must be aware of the process of raising a cashless claim in a health insurance plan. Let’s have a look.

Planned Cashless Hospitalization in Health Insurance

Here are the steps to be followed for planned hospitalization –

Contact your TPA (Third-Party Administrator) 

Inform your TPA about your hospitalization plan. If you have any particular network hospital in mind, then inform them about that as well. Ensure that you contact the insurer at least 3 days prior to your planned admission date.

Fill and Submit the Cashless Request Form 

This form can be availed at the network hospital’s help desk or reception. Once you have provided the details, get them certified by the prescribed doctor before submitting them to the TPA with the supporting documents.

Provide Additional Documents if Required 

The TPA will inspect the documents sent by you and communicate their decision with the hospital. At this point you may be asked for additional documents, so be prepared for the same.

Arrange for the Deductibles and Inadmissible Charges 

After receiving all the documents, the TPA will make the decision on your health insurance claims. If approved, they will make the payment in coordination with the hospital. You will have to pay the out-of-pocket expenses such as the deductibles and charges for things such as telephone, food, consumables, and so on.

A time frame of 24 hours may be required for the processing of your cashless hospitalization claims once the TPA has received your documents.

Emergency Cashless Hospitalization in Health Insurance

Here are the steps to be followed for emergency hospitalization –

Intimate the TPA 

Once the patient has been admitted into the network hospital, you should inform the TPA and give them the required details. Do remember to quote the health card number that you must have received along with your health insurance plan.

Fill the Cashless Request form 

Get the cashless request form from the hospital help desk, fill it up with the correct information, and make sure to get it authenticated by your treating doctor before submitting it to the TPA. Ensure that you attach the relevant medical records as well.

The next steps in the process are similar to the steps for planned cashless hospitalization.

If your cashless claim is not approved for some reason, then you will have to go ahead with the reimbursement claim process.

Some Things To Keep in Mind When Filing A Cashless Claim On Your Health Insurance Plan

  • Opt for an insurer that has a high number of network hospitals. This ensures that you have more accessibility to good quality treatment.
  • It is advisable to confirm the availability of cashless claims at a network hospital with the TPA before you take admission there. Health insurance companies review their panel of hospitals on a yearly basis and may remove a hospital from the list if it does not meet their standards anymore.
  • Opt for an insurer with a high claim settlement ratio as that will increase the probability of your claim being approved.
  • Even though cashless claims get processed quickly, you should still keep the bills, invoices, and hospital records in case they are required for future use.

The process mentioned here may not apply to all health insurance plans. It is always advisable to contact your TPA or the insurer and get detailed information about their unique cashless claims process.