Stages of a cashless claim cycle
A claim is a formal request to the insurance provider for reimbursement against losses covered under your insurance policy. There are two types of claim processes currently: Cashless claim & Reimbursement claim. In this article, we will be discussing the the claim journey of a cashless claim. If you wish to understand more about what is a cashless claim, then please read this guide.
A cashless claim means a specialized service provided by an insurance company or a third-party administrator (TPA), where the payment for the cost of treatment undergone by the policyholder is directly made by the insurer to the network provider in accordance with the policy terms and conditions. This service is only applicable when the patient has been admitted under a network hospital under their insurance policy.
The entire cycle for a cashless claim is as follows:
- Pre authorization: During the pre-authorization step, the hospital on behalf of the patient will request the insurer/TPA to make an initial approval of the treatment or surgery cost. The insured will need to inform the insurance desk at the hospital about the policy they hold, and submit any documents the TPA/insurer might demand. The cashless service would get initiated once the pre-authorization form is shared with the TPA/Insurer at the network hospital.
- TAT for further processing: The TAT for pre-authorization approval is between 2-3 hours, this could get delayed if any query is raised by the TPA/insurer. It should be noted that the pre-authorization approval is the initial approval with a part of the amount getting approved.
- Interim approval: Interim approval would be the approval stage before the final approval, the hospital would send an additional request to increase the approval value if the treatment expenses are increasing or the patient's stay in the hospital is extended than usual.
- Query: A query is raised when the insurer/TPA requires certain clarification regarding the cashless request from the hospital.
- Final Approval: Final approval is the request raised by the hospital to the TPA/Insurer desk for the overall total approval amount once the patient's treatment or surgery has been done.
It should be noted that the entire cashless claim has an ideal TAT for 3-4 hours (for final approval). However, due to certain queries being raised, the TAT might be lengthened until the TPA/insurer is satisfied with the proof submitted by the hospital. Also, non-medical expenses are non-consumable items like, gloves, pads, needles, admin charges, etc. will be treated as deductions in the final approved amount.
If you require any help or further assistance, kindly reach out to us at care@nova-benefits.com or 04049174207.
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