Documents Required for Cashless Health Insurance Approval

A family member has been told they need to be admitted to the hospital, and while their health is the first thing that comes to mind, you do not want the hospital staff asking around for documents you do not have on hand. We have all probably been in this situation before, and while the stressful environment can be overwhelming enough, the search for documents just adds to the confusion. 

The good news is that it is actually very simple to get your cashless health insurance claim approved, as long as you know which documents to keep in hand. This blog gives you a straightforward overview of all the documents you may need, and everything else you need to know. 

How Does Cashless Health Insurance Actually Work?

A standard health insurance claim usually requires you to pay the hospital first, and the insurer later reimburses you. Cashless health insurance is a completely different method, where the hospital receives the payment directly from the insurance company itself. This means that there is no out-of-pocket payment made by you at the hospital.

There is only one primary step needed for this, and it is pre-authorisation. The pre-authorisation is initiated by the hospital, which then sends out a request to the insurance company or their third-party administrator. The insurance company then approves the amount, and treatment is continued. It is important to know that this type of cashless service can only be opted for if you have been admitted to network hospitals. Network or empanelled hospitals have tie-ups with the health insurance company. It is important to check the list of your insurer before you go to the hospital for a claim. 

What is a TPA and Why is it Important?

A TPA (Third Party Administrator) acts as a mediator between you, the hospital, and the insurance company. This is the intermediary who will be responsible for any documents you hand over, all paperwork, as well as handling any queries regarding your pre-authorisation request and any other pre-authorisation-related documents. It is likely that during your hospital stay, you will be interacting with the hospital's TPA desk a lot more than you might interact with the insurance company directly. Every insurer has a TPA that works for them, although some large insurers may carry out most of their claims themselves. This is usually quicker as there is an entire level of communication removed. It is good practice to check this at the time of buying a policy.

What are the Documents Required for Cashless Health Insurance Approval?

Most people get confused at this point, but here is a simple breakdown of what documents are to be handed over when you are being admitted to a hospital in planned and/or emergency cases. 

For Planned Hospitalisation:

For planned hospitalisations, you typically have enough time to prepare. Go through the table and make sure you have all the documents prepared: 

Submit these at the hospital's TPA desk at least 48 to 72 hours before admission.

For Emergency Hospitalisation:

In emergencies, you may not have the time to submit every single document requested, but you are still required to notify the insurance company within 24 hours of admission. Most insurance companies have dedicated helpline numbers, which you would need to call. These are some documents that you should have with you to help make the process smoother: 

• Health card and Photo ID (these are the most important at this stage)
• Emergency admission notes by the hospital
• Doctor's assessment and diagnosis report
• Pre-auth form, once the patient is stabilised

Remember that the hospital's TPA desk will be your central point of contact for any claims. Talk to them right at the start of the hospital stay instead of leaving it for the last minute. 

How to Get Your Documents to the TPA Without Delays or Mistakes?

Sometimes, even the smallest error can make your claims process more complicated and longer. These are some tips to keep in mind so that your documents are delivered quickly and smoothly: 

Inform your Insurance Company at the Earliest: 

For planned hospitalisation, you should ideally call the insurer before admission and inform them. For emergency hospitalisation, notify your insurer within 24 hours of getting admitted to the hospital. Late intimation is often the most obvious reason for any claims process being delayed or put on hold.

Complete your Pre-Authorisation Form Correctly: 

If the document submitted has not been completed properly, it will always be sent back to you, and that can result in delays. Ensure that the doctor fills out the relevant details. Ask the TPA to look at it once to make sure nothing is missing before you submit it. 

Keep Digital Copies: 

It is always a good idea to take scanned or photographed copies of all the documents before you submit them. Hospital stays often extend beyond the time allotted, and a copy of the documents will always save you time later on.

Verify the Hospital's Network Status: 

Before you make plans to admit your family member to any hospital, make sure that the hospital is on your insurer's list and that they have a tie-up with that hospital. You can always find this list of hospitals online on the insurer's website or through their app. 

Track your Pre-Authorisation Status: 

Most insurers allow you to track the status of your pre-authorisation by using their website or mobile app. If you are worried and have not received any response from the insurance company or TPA desk within hours after submitting, contact them as soon as possible. 

What Will Happen After the Pre-Authorisation Gets Approved?

Once the insurance company approves the pre-authorisation request, you will be notified, as will the hospital. The hospital will then provide you with confirmation that your pre-auth request has been accepted and the amount they are going to approve. Treatment will be carried out, and all covered costs will be settled by the insurance company. 

It is important that you review all the hospital bills carefully, as there will be discharge costs that may not be covered by your insurer. Make sure to be aware of all additional costs, including new tests, room rents, and other medical expenses.  After all medical expenses are settled, remember to ask for all hospital bills and the discharge summary, as these will be needed for your income tax claims.

A small checklist to keep handy:

• Insurer intimated
• Health card and ID ready
• Pre-auth form submitted
• Investigation reports attached
• Digital copies saved
• Final discharge summary collected

What Can Cause Your Cashless Claim to be Rejected?

Rejections can be painful, but they are usually preventable. Here are the common causes and what to do about them:

• Missing/Incomplete Docs: 

The pre-authorisation form is not filled out completely, or a required report has not been attached.  

• Policy Lapse:

 If you have forgotten to renew the policy, cashless is not applicable.   

• Non-Covered Treatment: 

Some treatments, like cosmetic surgery or certain conditions requiring waiting periods for pre-existing issues, may not be covered by the policy.  

• Wrong Hospital:

You have got yourself admitted to a hospital that is not part of the insurer's network.  

• Late Intimation:

The hospital has failed to inform the insurer about the hospitalisation within the given time. 

• Patient Details Mismatch: 

The health card has your name and date of birth, which does not match the hospital records.  

Making Cashless Claims as Easy as Possible

Most issues with cashless claims are mainly because of not being prepared enough. The documents required are typically already with you. It is simply that the accuracy of details can cause complications. 

We, at Niva Bupa health insurance policy, offer a hassle-free cashless claims process. We have a wide network of cashless hospitals spread across the country, a 24/7 helpline, and a simplified pre-authorisation process. This ensures that when you are faced with a situation where you actually need to use your policy, you are not left figuring it out on your own. 

FAQs

Can I Use Cashless Health Insurance If I'm Hospitalised in a Different City?

Yes, cashless claims work across India as long as you are admitted to a hospital that is in your insurer's network. Before heading to any hospital, make sure to check if the hospital is listed on your insurer’s website or app. 

Does Cashless Health Insurance Cover Daycare Procedures That Don't Require a 24-hour Stay?

Most modern health insurance plans, including Niva Bupa's, do cover a wide range of daycare procedures like cataract surgery, chemotherapy, or dialysis that are completed within a few hours. The cashless process applies here, too.

What Happens to My Cashless Claim if the Treating Doctor Changes Mid-Hospitalisation?

If your treating doctor changes during the hospital stay, inform the TPA desk immediately. The pre-authorisation is linked to the treatment plan, not just the doctor, so in most cases the claim continues without disruption. However, if the new doctor recommends a different course of treatment, a fresh or revised pre-authorisation request may need to be submitted.