SZ TPA Website Extracts useful & other Relevant Info,CARE

1)Here are some select useful Extracts from South Zone TPA VidalHealth Services

This is just for info.Final advice & instructions will come from respective LIC divisions & ZO.It appears Ecards are ready & TPA Managers,Customer Care & others are handing over to respective LIC controlling authorities 

2)Whatever it is,we have to exercise great care,diligence,discipline & promptitude & keep all relevant records with adequate copies early to avoid search & also to keep family members informed.As timelimits are prescribed, EXTRA CARE & PRECAUTION has to be exercised.We have to find fault with ourselves & not others

3)Further,everyone of us will have to maintain sound public relations with Pension disbursing office & officers/staff dealing with  mediclaim settlement

Any doubt or clarification will have to be sought from the Authorities only.

We can only help you to the extent possible because of inherent limitations.

We are radiating lot of useful info & data,procedures but primarily,you must be conversant with all what is called for & not raise same issue agaian & again

Many times, we have circulated SZ PENSIONERS HANDBOOK ,which was found useful by All India too.Equally,many other releases from EASTERN NEWS,Kolkata,our website airiefvision.wordpress.com or rksahni.blogspot.in contain Step by Step,pithy,procedure summary as a Control chart.This acts as a Ready Reckoner

4)LIC identity card with photo or any other usual valid Identity card with photo.ii)TPA Ecard iii)Better preserve  Yly Family particulars Form we complete for which Reply from LIC Office indicating Members eligible for the Yly Mediclaim cover,indicating Optional Sum Assured,I have stressed to SZO the importance of indicating OSA as that will serve eminent purpose to decide quickly  admission to hospital

With all these also,it is not going to be an easy smooth cashless admission to Hospital, when one glances thro the strict,methodical procedure outlined

5)We are very happy that RMOS & others at ZO had full scale discussions with TPA Officers.I had talks twice with them.They appear to be good listeners,empathetic & all assurances they gave.We have to elicit cooperation,it is a 2-way affair.Remember name, SR No, Date of Birth.  Keep record of the Names of 2 TPA Officers I gave in my earlier Email ,noting Tel Nos. We await LIC instructions soon

Greetings

RBKISHORE

VP,AIRIEF

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From TPA WEBSITE:

Cashless Hospitalisation

Health Insurance earlier entailed the complete settlement of the health care services bill by the individual to the hospital, followed by a reimbursement claim filed with the Insurance Company. The Insurance Regulatory Development Authority in India initiated the Cashless Hospitalization Process through Third Party Administration services for Health Insurance claims from 2002.

·         Once you are covered under a Health Insurance Policy administered by us, you will be issued a Vidal Health TPA ID card. If your health insurance cover is issued through your employer, you may not be issued a physical ID card but you may have a E-card. This card will facilitate you to avail CASHLESS facility at the Networked Hospitals.

·         Cashless hospitalization can be availed only at our network hospitals. The essence of cashless hospitalization is that the insured individual need not make an upfront payment to the hospital at the time of admission.

·         Cashless is only a facility extended by the Third Party Administrators to the Insured persons through their Network of Hospitals who have agreed to certain terms and conditions.

·         Cashless cannot be claimed as a matter of right and denial of a pre-authorization request is in no way to be construed as denial of treatment or denial of coverage or denial of your right to prefer reimbursement claim. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.

·         If the policy covering you is subject to the GIPSA PPN arrangement, please check for the nearest hospital that is in the GIPSA PPN Package Agreement. Cashless facility for such policies will be available only in those hospitals who are under the GIPSA PPN Arrangement.

Process for availing Cashless Hospitalisation Facility

·         Plan admissions only in such hospitals that are in our Network. If your policy is subject to GIPSA PPN Network, please get admitted only in such hospital that is in the GIPSA PPN Network. Your admission elsewhere will lead to denial of the cashless facility and even reimbursement of the expenses will be subject to the limits as per the GIPSA PPN Tariff.

·         Produce the ID Card issued by us at the Hospital Help Desk – along with any other ID Proof like DL/ Voter’s ID/ Passport etc in respect of THE PATIENT.

·         Obtain the Pre-authorisation Form from the Hospital Help Desk, complete the Patient Information and resubmit to the Hospital Help Desk.

·         Please indicate our ID Card Number without fail. In case the policy is taken by your employer you may also furnish the Employee Number.

·         The Treating Doctor will complete the hospitalisation/ treatment information and the hospital will fill up expected cost of treatment.

·         This form is submitted to us either online or by fax.

·         We will process the request and call for additional documents/ clarifications if the information furnished is inadequate.

·         Once all the details are furnished, we will process the request as per the terms and conditions as well as the exclusions therein and either approve or reject the request based on the merits of the case.

Once the request is received, it is processed. Our medical team will determine whether the condition requires admission and the treatment plan is covered by your Health Insurance Policy. They will also check with all the other terms and conditions of your Insurance Policy.

In case coverage is available, we will issue an approval to the hospital for a specified amount depending on the disease, treatment, sum insured available etc. We will send the Approval Letter for Cashless Facility by fax and e-mail (if available) to the Hospital. This approval is called “Pre-authorisation”. This pre-authorisation entitles you to avail the treatment at the hospital without paying for the medical expenses up to the authorised limit. 

At the time of discharge, in case the amount authorized by us is not sufficient to cover the hospitalization expenses, the hospital will make a second/ final request on your behalf for sanction of additional amount. We will process this request and sanction of an additional amount will be made subject to terms and conditions of your health insurance policy.

Your policy may be subject to ‘Co-pay’. This is the compulsory amount that you need to bear in respect of each and every hospitalisation claim. Please check for this information. You are required to pay to the hospital the amount equal to the co-pay and obtain the necessary Bill & receipt. The hospital has to submit the proof for having collected this amount from you. If the hospital is not able to produce the requisite proof in respect of collection of co-pay from you, twice the amount of co-pay will be deducted as a penalty from the amount payable to the hospital.

Please verify your policy benefits to check your eligibility for Room Charges etc. An admission to a ward higher than your entitlement would cost your claim as the amount payable will be reduced in proportion the eligible ward charges bear to the higher ward charges billed.

Once final sanction has been received by the hospital, please make sure that you check and sign the original bills and Discharge Summary. Please carry home a copy of the signed bill and the Discharge Summary and all your investigation reports. This is for your reference and will also be useful during your future healthcare needs.

The hospital will ask you to pay for all the Non-admissible Expenses in your bill. You have to make this payment before discharge. You may check for the items disallowed against the Annexure IV of the ‘Standard List of Excluded Expenses in Hospitalization Indemnity policies’ of Exposure Draft – Health Insurance’ by IRDA in the website. 

In case, for whatever reason, the pre-authorisation request cannot be approved, a letter denying preauthorization will be sent to the hospital. We may deny the Pre-authorisation without assigning any reason. We may not be able issue Pre-authorisation probably due to insufficient information either from the service provider or the Insurer. In such case, you will have to settle the hospital bill in full by yourself. 

Please note that denial of a Pre-authorization request is in no way to be construed as denial of treatment or denial of coverage. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.

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Frequently Asked Questions

·         Why did TTK Healthcare TPA’s name change to Vidal Health TPA?

TTK Healthcare TPA has been acquired by Vidal Healthcare founded by Mr. Girish Rao. This was a strategic move by Vidal Healthcare to become an integrated Healthcare solutions Organization by creating synergy between the TPA and wellness businesses.

   

·         What is the procedure to avail cashless facility? 

Customer needs to drop into a Vidal Health TPA Pvt. Ltd. network hospital to give a copy of his/her Vidal Health TPA ID card and Identity proof at Hospital reception. Pre-authorisation form has to be filled which has two parts. Part 1 needs to be filled by the patient or the patient’s family and part 2 needs to the filled by the Hospital authority/Treating doctor. The completely filled form should be faxed or mailed to Vidal Health TPA Pvt. Ltd (respective branches). Once pre-authorisation form is received by Vidal Health TPA Pvt Ltd., the case will be processed within 4 hours and the initial authorization letter (approved or rejected) will be faxed/emailed back to hospital by Vidal Health TPA Pvt. Ltd.
Note:-
For planned hospitalization: - Pre-authorisation form to be sent before 48 hours of hospitalization.
For Emergency: - Pre-authorisation form to be sent within 6 hours from the time of admission.

·         What is the TAT to process the enhancement (Final approval)?

On the date of discharge hospital team have to send the final bill with break up and discharge summary to Vidal Health TPA Pvt Ltd. After the receipt, within 2 hrs the enhancement (as per policy limits) will be processed after deducting the non medical expenses (paid by the patient) and approval letter will be sent to hospital fax or email.
Note: - Co pay (if applicable) has to be paid by the Policy holder
Some of the Hospitals are Preferred Provide Network (PPN), Gipsa and Hospital tariff, if cashless is taken in those hospitals the final approval will be as per the respective tariff.

·         What is the TAT to process the pre-authorisation once shortfall query is responded?

Once the shortfall is responded, within 2 hours the case will be processed.

·         What is the procedure to cancel the cashless approval?

Hospital team needs to send the letter/fax/email to Vidal Health TPA Pvt. Ltd., asking them to cancel the approval. The cancellation letter will be sent to hospital within 2 hours.

·         Is there any time limit to submit the Pre-authorisation request?

Yes. If it is a planned hospitalization then the pre-authorization request needs to be sent before 48 hours from the date of admission. In case of emergency the pre-authorisation request needs to send within 6 hours from the time of admission.

·         Do I need to pay any amount to the hospital while getting discharged for Cashless hospitalisation?

Yes. The policy holder needs to pay the non medical expenses and the co-pay amount (if applicable). He will need to pay the difference amount (difference between the final bill and approved amount).

·         What are Non-Medical expenses?

Non Medical expenses are: Admission fees, Registration fees, gloves, blade, water bed, food & beverages, extra bed etc.,

·         Is there any minimum time limit for stay in the hospital?

Minimum 24 hours of hospitalization (if not day-care) with active line of treatment is required for cashless treatment
However, there are a few specific ailments specified in the policy which can be covered even though the period of hospitalization is less than 24 hours. Such as
Dialysis, Chemotherapy, Radiotherapy, Eye Surgery etc.,

·         What is Cashless Rejection ?

Rejection will be done as per the policy terms and coverage, the below are the few examples for rejection.

a. If hospitalization is for observation & investigation purpose
b. If any particular aliment/disease/treatment is found not covered under policy term and condition
c. If found that the treatment can be done under OPD basis
d. If found that no active line of treatment is available
e. If Shortfall and the policy holder has not responded within the given TAT
f.  If policy is invalid
g. Rejection of cashless is not a denial of treatment

·         What if the cost exceeds the level of hospitalization insurance cover ?

In such a situation the policy holder will be liable to pay the difference amount. We will inform the hospital about the policy holder’s eligible amount and hospital will recover the amount over and above the credit amount from the policy holder directly.

·         What are the different types of Claims ?

Member Claim and Network Claim (for Hospital)

·         How will I be intimated about the Claim ?

Policy holder has to intimate Vidal Health TPA Pvt. Ltd.,  before sending the claim documents if he/she wants to claim after discharge, Intimation has to be given within the TAT as per the insurance company.

·         What is the procedure of Reimbursement?

Policy holder will need to download the claim form No 9 from our website www.vidalhealthtpa.com. The claim form contains 4 pages which includes medical certificate also. The medical certificate needs to be filled in by the Treating doctor with hospital seal and doctor’s signature. The policy holder should fill the claim form and should attach all his original bills and send a courier to Vidal Health TPA Pvt. Ltd(respective branches).
Note: - The claim documents has to reach Vidal Health TPA Pvt. Ltd., within the TAT as per the Insurance company TAT

For all United India Insurance policy holder ECS is mandatory, they have to send ECS form along with the cancelled cheque with the original claim documents.

·         What is the TAT to process the reimbursement (Claim)?

Once Vidal Health TPA Pvt. Ltd., receives the claim documents, Claim will get processed within 21 working days

·         Once the claim is processed within how many days I will receive the cheque?

Cheque will be dispatched within 7-10 working days from the date of approval.

·         How does Vidal Health TPA assess the claim?

Vidal Health TPA Pvt. Ltd. will assess the validity of the claim based on the documents submitted, validate the policy, validate the treatment undergone and settle the claim within the claim settlement parameters. In case of claim is not adhering with parameters, the case would be rejected.
Vidal Health TPA Pvt. Ltd. will correspond with you within 7 days of Claim receipt -
If Documents are not completed then Vidal Health TPA Pvt. Ltd. will request for the shortfall documents

·           If Claim is rejected then a Rejection Letter will be sent

Note: If any bills and receipts are not supported by valid documents, then the claimed amount of that bill will not be processed.

·         Will i get intimation for my claim status?

Yes, you will be intimated on your claim status to your updated email id from our database.

·         How can I check my Claim Status?

You can login to your account in our web portal or you can call our call center to check the claim status.
 

·         What are the documents that I should submit for reimbursement?

You should submit the entire set of ORIGINAL DOCUMENTs like

a. Claim form duly signed
b. Vidal Health TPA card (photo copy)
c. Identity Proof (photo copy)
d. Discharge summary with seal & signature of the hospital authority
e. In-patient bills
f.  Doctor’s prescription
g. Pharmacy bills with break ups
h. Investigation reports like MRI, ECG, CT scan, and X-Ray etc
i.  Laboratory reports
j.  Paid receipt with hospital seal & signature
k. Hospital registration copy (if required)

·         What are shortfall documents (S/F)?

Shortfall documents are those which are not submitted by the claimant, which is mandatory for further claim process.

·         Where and how can I send the Shortfall Documents? 

You can send the shortfall documents to respective Vidal Health TPA Pvt. Ltd. branch through post/courier or by walking in to respective branch.

·         What is the TAT for submitting the Shortfall documents?

You should send within 7 working days from the date of receiving the S/F query/letter.

·         What is disallowed amount?

The amount which is not approved is disallowed amount such as Non medical expenses, no proper bill break up, Lab report not submitted aliment capping, exceeds Sum insured / aliment limit Etc

·         What is Claim Rejection?

Refer cashless rejection, a part from those the below are the few reasons for claim rejection
Claim docs not submitted within the given TAT
Claim intimation not given
Date of inception is greater than date of admission
Fraud Case

·         What is Day-Care Surgeries?

Day Care surgeries are those which do not require 24 hours of hospitalization such as Cataract (Eye) surgery, Dialysis, Kidney stone removal, Chemotherapy, D&C etc.

·         Day care surgeries are payable or not?

Depending on Insurance policy some of the day care surgeries are payable according to term and conditions.

·         How can I download Vidal Health TPA card soft copy (E Card)?

You can login to your account in Vidal Health TPA web portal and download E Card or call the call center and place the request.
 

·         I am using a TTK Health card ; will my card be accepted for cashless hospitalization / Reimbursement?

The TTK Health card both Physical and E-cards will still be valid at all network hospitals for Cashless Hospitalization. All the hospitals are informed to accept TTK cards also.

·         Will Vidal Health TPA’s phone numbers, fax and e-mail addresses are the same?

All the contact details have been updated in the website. Please note that our e-mail will now read name@vidalhealthtpa.com instead of name@ttkhealthcareservices.com

Collections from SZ TPA WEBSITE  www.vidalhealthtpa.com       

 R.B.KISHORE,VP,AIRIEF

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R.B.KISHORE,VP,AIRIEF
ED(Retd),LIC,PROBUS LIFE MEMBER,
044-28155810 / 098403 40591