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TPAs in Kharghar

Samarth Nethralaya has a tie-up with several TPAs in Kharghar.

All the original documents including bills, lab reports, discharge summary, and claim form. All the original documents duly signed by you need to be submitted to the hospital.

For complete details on the medical expenses that are covered, and those that are not covered, you need to go through your health insurance policy. However, in general, the expenses listed below are not reimbursable under cashless hospitalization.

  • Registration/Admission Fee
  • Telephone Charges
  • Visitors / Attendees Charges
  • Ambulance Charges
  • Charges for Diet, which is not part of the administered treatment
  • Document Charges
  • Toiletries
  • Non-medical Expenses
  • Service Charges/Surcharges
    These need to be settled by you directly to the hospital at the time of discharge.

In case your hospitalization expenses exceed the pre-approved amount, you can approach the Help Desk to apply for an enhancement of the pre-approved amount. The Help Desk will apply for enhancement on your behalf with the TPAs  and provide the necessary documentation. In case you have not exhausted your medical insurance limit, it is most likely that your TPAs in kharghar will approve the application for the enhancement – either for the requested enhanced amount or up to your insured limit after deducting the value already utilized by you during the year – whichever is less. If the TPAs in kharghar turns down the request for enhancement you will need to pay the amount incurred in excess of your approved amount directly to the hospital before the discharge.

Normally your request for approval might be rejected when :

Information contained in the pre-authorization form is insufficient for the TPAs in Kharghar to arrive at a decision and further information is not available for various reasons. However, the chances of rejection under this criterion are rare since the Help Desk at the hospital is experienced in complying with pre-authorization formalities and will advise you suitably.

The ailment for which hospitalization is being sought by you is not covered under your insurance policy for reasons like pre-existing ailment, specific exclusions (accident admission under the influence of alcohol)

You have exhausted your eligible Medical Insurance cover for the year.

Cashless hospitalization is linked to the approval of the estimated expenditure on your proposed treatment. In case you do not get your approval you will need to bear the entire expenditure incurred on the treatment. Therefore it is always prudent to get the approval and then get yourself admitted. You could explain the benefits of getting the approval before the date of your admission to your treating doctor as well when he recommends an immediate admission.

At Samarth Nethralaya, (TPAs in kharghar) the Help Desk will not entertain any request for a refund of the amount paid if the approval comes after the process for your discharge has commenced.

Hospitalization happens under two circumstances Planned and Emergency. Pre-authorisation of the estimated hospital expense is a must to avail of this facility.

Planned Hospitalization: In the case of planned admission, you would have first consulted a doctor who in turn would have advised you on the probable date of hospitalization. In such a case, you must have applied for approval of the estimated hospital expenses directly with your TPAs in Kharghar at least 4-5 days prior to the date of hospitalization.

In case you have not applied for a pre-authorization sufficiently in advance or if the doctor treating you advises you to get hospitalized immediately after the consultation, our Help Desk will assist you through the pre-authorization procedure.

However, you will need to bear in mind that the Help Desk is only a facilitator and can in no way influence the decision on the approval. The approval can be turned down.

The pre-authorization procedure is detailed below:

Step 1: Establish contact with the Help Desk at the Hospital.

Step 2: At the Help Desk, you need to present the original health Insurance card issued to you by your TPA.

Step 3: Collect the pre-authorization will form pertaining to your TPA

Step 4: Your pre-authorization will have two sections –

General details on the health Insurance policy – to be filled in by you (the help desk will assist you in case you have any difficulty)

Pertains to the treatment recommended for your needs to be filled in and duly signed by the Doctor who is treating you do not attempt to fill this section, contact the help desk in case of any difficulty)

Step 5: Return the completed form to the Help Desk. The personnel at the desk will verify the form for its completeness and let you know in case of any discrepancies.

Step 6: Once the form is complete in all respects, the Help Desk will fax the form to the office of your TPA.

Step 7: The Help Desk will revert to you on the approval status

Emergency Hospitalization: In case of emergency hospitalization, the help desk will take up your case on a fast track basis with your TPA and is likely to receive approvals within 3 hours during any working day,

For cashless treatment, it is mandatory for the hospital to have approval from your TPA. In case of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency, you can undertake the treatment by paying the necessary cash deposit.

If you receive approval from your TPA after paying the cash deposit, you are entitled to a refund of the cash deposit.

First, you need to be clear that there is no free treatment. It is just that, in the case of cashless hospitalization, the insurance company will bear the cost of treatment either fully or partially on your behalf.

Cashless hospitalization is a facility provided by most health insurance policies and enables an insured customer to obtain admission and undergo the required treatment without direct payment. The assigned TPA will mediate between the healthcare service provider (hospital) and the insurance company and settle the bills on behalf of the insured customer.

However, it is important to understand the role of a hospital in cashless hospitalization. The hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalization. Certain protocols laid down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalization will need to be adhered to strictly.

Today, most Health Insurance policies do offer a cashless hospitalization facility and route your policy through a Third-party Administrator (TPAs in Kharghar). However, you should be familiar with the terms- Network Hospital and Non-network Hospital.

Network Hospitals are those hospitals that your TPAs in Kharghar has an agreement with. In case of hospitalization, if you get admitted to a Network Hospital you will be eligible for cashless hospitalization, subject to the other terms and conditions mentioned in your policy being fulfilled. In case you are admitted to a Non-network Hospital, you will have to settle the bills directly to the hospital and then seek reimbursement through your TPA.

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