CASHLESS CLAIM FORM Toll Free No. 1800-345-3323 TO BE ...

1 CASHLESS CLAIM FORMTO BE FILLED IN BY THE HOSPITALThe issue of this form is not to be taken as an admission of liabilityPlease include the original preauthorization request from in lieu of PART A(To be Filled in block letters)DETAILS OF HOSPITALa) Name of the hospital :b) hospital ID:d) Name of the treating doctor:e) Qualification:DETAILS OF THE PATIENT ADMITTEDc) Type of hospital :Network :Non Network :(if non network fill section E)f) Registration No. with State Code:g) Phone ) Name of the Patient:b) IP Registration Number:c) Gender:MaleFemaled) Age: YearsMonthse) Date of birth:ii) Gravida Status: :m) Total claimed amounth) Date of Discharge:I) Date of Delivery: k) If MaternityMaternityDay CarePlannedEmergencyf) Date of Admission:j) Type of Admission:I) Status at time of discharge:Discharge to homeDischarge to another hospitalDeceasedDETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD 10 CodesI.

2 Primary Diagnosis: ii. Additional Diagnosis:iii. Co-morbidities:iv. Co-morbidities:vi. If not reported to police give reason:Descriptionb) I. Procedure 1:ii. Procedure 2:iii. Procedure 3:iv. Details of Procedure:ICD 10 PCSD escriptionc) Pre-authorization obtained: YesYesYesYesNoNoNoNod) Pre-authorization Number:e) If authorization by network hospital not obtained, give reason: f) Hospitalization due to injury:I. If Yes, give cause Self-inflictedRoad Traffic AccidentSubstance abuse / alcohol consumptioniv. Reported to Policeiii. If Medico legal:(If Yes, attach reports)ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:v.

3 FIR DOCUMENTS SUBMITTED - CHECK LISTC laim form duly signedOriginal Pre-authorization requestCopy of the Pre-authorization approval letterCopy of Photo ID Card of patient Verified by hospitalHospital Discharge summaryOperation Theatre NotesHospital main billHospital break-up billInvestigation reportsCT/MR/USG/HPE investigation reportsDoctor s reference slip for investigationECGP harmacy billsMLC reports & Police FIRO riginal death summary from hospital where applicableAny other, please specifyDETAILS IN CASE OF NON NETWORK hospital (ONLY FILL IN CASE OF NON-NETWORK hospital )(PLEASE READ VERY CAREFULLY)a) Address of the Hospitald) hospital PAN:iii.

4 Others:DECLARATION BY THE HOSPITALWe hereby declare that the information furnished in this CLAIM form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,our right to CLAIM under this CLAIM shall be :Place:Signature and Seal of the hospital Authority:SECTION ASECTION BSECTION CSECTION DSECTION ESECTION FYesNoYesNoCity:State:Pin Code:b) Phone ) Registration No. with State Code:e) Number of inpatient bedsf) Facilities available in the hospitali. OT ii. ICUYesNoSURNAMEFIRST NAMEMI DDLENAMESURNAMEFIRST NAMEMI DDLENAMEDDMMYYHHMMYYMMMMMMDDDDHMHMYYDDMM YYDDMMYYYYg) Time: Toll Free No.

5 1800-345-3323 Fax No. 95-120-4144170-71 GUIDANCE FOR FILLING CLAIM form - PART B (To be filled in by the hospital )DATA ELEMENTDESCRIPTIONFORMATa) Name of the hospital :b) hospital IDc) Type of Hospitalc) Name of treating doctorSECTION A - DETAILS OF HOSPITALe) Qualificationf) Registration No. with State Codeg) Phone the name of hospitalEnter ID number of hospitalIndicate whether in network or non network hospitalEnter the name of the treating doctorEnter the qualification of the treating doctorEnter the registration number of the doctor along with the state codeEnter the phone number of doctorSECTION B - DETAILS OF THE PATIENT ADMITTEDa) Name of Patientb) IP registration Numberc) Genderd) Agee) Date of Birthf) Date of Admissiong) Timeh) Date of Dischargei) Timej) Type of Admissionk) If MaternityDate of DeliveryGravida Statusl)

6 Status at time of dischargeM) Total claimed amountEnter the name of patientEnter insurance provider registration numberIndicate Gender of the patientEnter age of the patientEnter date of birthEnter date of admissionEnter Time of admissionEnter date of DischargeEnter time of DischargeIndicate type of admission of patientEnter Date of Delivery if maternityEnter Gravida status if maternityIndicate status of patient at time of dischargeIndicate the total claimed amountSECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD 10 CodePrimary DiagnosisAdditional DiagnosisCo-morbiditiesb) ICD 10 PCSP rocedure 1 Procedure 2 Procedure 3 Details of Procedurec) Pre-authorization obtainedd) Pre-authorization Numbere) If authorization by network hospital not obtained, give reasonf) Hospitalization due to injuryCauseIf injury due to substance abuse/alcohol consumption test conducted to establish thisMedico LegalReported to PoliceFIR not reported to police, give reasonIndicate which supporting documents are submittedSECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LISTSECTION E - DETAILS IN CASE OF NON NETWORK HOSPITALa) Addressb) Phone ) Registration No.

7 With State Coded) hospital PANe) Number of Inpatient bedsf) Facilities available in the hospitalRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stampEnter the ICD 10 Code and description of the primary diagnosisEnter the ICD 10 Code and description of the additional diagnosisEnter the ICD 10 Code and description of the Co-morbiditiesEnter the ICD 10 Code and description of the first procedureEnter the ICD 10 Code and description of the second procedureEnter the ICD 10 Code and description of the third procedureEnter the details of the procedureEnter pre-authorization numberIndicate whether pre-authorization obtainedEnter reason for not obtaining pre-authorization numberIndicate if hospitalization is due to injuryIndicate cause of injuryIndicate whether

8 Test conductedIndicate whether injury is medico legalIndicate whether police report was filedEnter first information report numberEnter reason for not reporting to policeEnter the full postal addressEnter the phone number of hospitalEnter the permanent account numberEnter the number of inpatient bedsIndicate facilities available in the hospitalSECTION F - DECLARATION BY THE HOSPITALName of the hospital in fullAs allocated by the TPATick the right optionName of doctor in fullAbbreviations of educational qualificationsAs allocated by the Medical Council of IndiaInclude STD code with telephone numberName of patient in fullAs allotted by the insurance providerTick Male or FemaleNumber of years and monthsUse dd-mm-yy formatUse dd-mm-yy formatUse hh:mm formatUse dd-mm-yy formatUse hh:mm formatTick the right optionUse dd-mm-yy formatUse standard formatTick the right optionIn rupees (Do not enter paise values)Include Street, City and Pin CodeInclude STD code with telephone numberAs allocated by the City Corporation / MunicipalityAs allocated by the Income Tax DepartmentDigitsTick the right option.

9 If others, please specifyStandard Format and Open textStandard Format and Open textStandard Format and Open textStandard Format and Open textStandard Format and Open textStandard Format and Open textOpen textTick Yes or NoAs allotted by TPAOpen textTick Yes or NoTick Yes or NoTick the right optionTick Yes or NoTick Yes or NoAs issued by police authritiesOpen textEnter the registration number of the hospital obtained from local bodylike City Corporation / Municipality