Health Insurance Orientation Module. Future Generali Health

Transcription

1 Health Insurance Orientation Module

2 Introduction Future Generali is an insurance joint venture between the Italy-based Generali Group and the India-based Future Group. Future Generali operates Life and Non-Life insurance businesses through Future Generali India Life Insurance Co. Ltd. and Future Generali India Insurance Co. Ltd. Future Group holds 74% each in both the companies. Future Generali received license from the Insurance Regulatory Development Authority (IRDA) in Sept 2007 and launched operations from Nov 2007.

3 Introducing

4 How we are different: (FGH) is an internal unit of Future Generali India Insurance. No Third Party Administrator (TPA) involved between the insurer and FGH. Claim settlement is faster due to single point clearance no exchange of claim documents between insurer and TPA. Preferred services extended as FGH provides service only to clients insured by Future Generali.

5 An In-house Health Management Team of Future Generali India Insurance Co. Ltd. Internal units of (FGH) Team Call Centre Enrolment Cashless Management Claims Processing Provider Management Research and Analysis Pre Policy Underwriting 24 X 7 Helpline to cater to customer queries For card issuance and member data management 24 X 7 services with 2 hours Turn Around Time (TAT)** Average TAT of 14 working days** 1800 hospitals and 200 diagnostic centers network Analysis, Feedback & monitoring For retail medical underwriting Centralized Group / Retail Underwriting at hubs **All TAT s subject to availability of complete documentation

6 Your New Wellness Card Your New card entitles you to a host of healthcare benefits. Photo identification is necessary whenever you use this card. This card does not entitle you to avail cashless without pre-authorization. This is NOT a credit card.

7 Member Enrolment Key Function: For card issuance and member data management Within how many days will I get my Wellness Card? You will receive health cards via courier or within 7 days after your details are received by FGH from your organization. What if there is an error on my Wellness Card? For any error in cards or correction required, you can immediately report to your HR. What is the use of the Wellness Card? You will get a Wellness Card to utilize the Cashless facility at Network Hospitals. This card helps only in your identification as a member. Availability of Cashless and any other benefit is subject to policy

8 Claim Process: Cashless If you are going for a Planned Hospitalization: 1. Carry your ID cards and authorization letter when you go to the hospital for admission 2. Get the Pre-authorization done in at least 7 days before hospitalization 3. Pre-authorization is done to determine whether cashless facility can be granted based on all medical information about your ailment and coverage 4. Pre-authorization forms are available at NETWORK hospitals. You can also obtain it from our call centre by e or Fax 5. Your treating doctor has to fill the form and sign it 6. You will also have to sign the Pre Authorization form and provide e your mobile number 7. The hospital will fax this form to our Call Centre to get an authorization

9 Claim Process: Cashless Continued. If you are going for Planned hospitalization: 8. Our doctors will examine the form and decide on cashless availability ility 9. If cashless is granted, we will send an Authorization Letter to the hospital. You can also get a copy of the Authorization Letter from our Call Centre by e 10. If cashless is denied, we will send a Denial Letter to the hospital and inform you 11. If cashless has been denied, you will have to pay the hospital bill b and then send the claim to us

10 Cashless Process Customer approaches FGH Toll Free for Cashless Treatment. Future Generali coordinates with hospital for preauthorization Hospital verifies customer details and sends pre-auth by fax to FGH (Pune) FGH verifies pre-auth details with policy benefits and sends the response by Fax to Hospital Network Hospital Approved Query Denial Authorization Letter sent by FGH Query Letter sent by FGH Denial Letter sent by FGH Hospital admits the patient without any deposit and provides cashless treatment Hospital faxes the reply for queries asked by FGH doctors Hospital admits the patient as Cash Patient and patient pays the Bill

11 Cashless Process FAQs 1. What is a Network Hospital? How do I know the hospital is on the network? FGH has tied up with specific hospitals and nursing homes to provide preferred services to its customers. These hospitals are termed as Network hospitals. You can find out the details of Network hospitals in your city from f our Call Centre on phone or by . e The details are also available in the Health Insurance Guide sent along with your Wellness Card. Hospitals are added and removed from the network at regular intervals. You are advised to check with our Call Centre for the updated status of any hospital.

12 Cashless Process FAQs 2.How does the Hospital verify that the cardholder is genuine? Since the Card issued is not a photo id card, you are required to submit a photo id to verify the genuinity of identity at the Admission Desk of the Hospital. The photo id can be your Organization Identity Card, Driving License e or any other such card which will help the hospital to establish the genuinity y of the patient. 3.What is a Preauthorization Request? This is a Request for Cashless Hospitalization. The same has to be duly filled up, signed and stamped by the Hospital Authorities. Thereafter it has to be sent by fax / e to FGH. The Contact details of FGH is available in the hospital.

13 Cashless Process FAQs 4.Where do I procure the Preauthorization Request from? The Preauthorization Form template is available with the Network Hospitals or also enclosed with the Health Insurance Guide. It can also be obtained from FGH Call Centre on phone or by . e 5.How to fill the Preauthorization form? It must be filled by the Treating Doctor. Information required are : ID No. as printed on the Card, Signs and Symptoms of the present aliment, duration of the aliment, diagnosis, pre existing conditions if any, a proposed line of treatment, expected date of admission, duration of stay and estimated cost of hospitalization.

14 Cashless Process FAQs 6.Where do I send the Preauthorization form? The Preauthorization Request for Cashless Hospitalization can either be faxed to 24 x 7 Toll Free Fax-line or mailed to [email protected] 7.What is an Authorization Letter? Authorization Letter is the communication ascertaining the Admissibility sibility or Acceptance of the Cashless Service. The same is issued by FGH subject to admissibility of the claim and availability of balance sum insured for the member. 8.Is the entire amount requested by hospital authorized by FGH? FGH would release a part or the entire amount depending on the ailment a and related expenses. In case a part amount has been approved by FGH,, then the hospital would ask for additional authorization when necessary.

15 Cashless Process FAQs 8.How do I know whether my Claim has been approved for Cashless or not? Authorization Letter or Denial Letter shall be faxed directly to the Hospital with intimation to you. A Query letter shall be faxed to the hospital if in case FGH wants some additional information to decide upon the admissibility.

16 Cashless Process FAQs 9. What are the circumstances under which a Request for Cashless Hospitalization shall be denied? 1. If the information contained in the Request is insufficient for FGH to arrive at a decision and further information is not available for r whatever reasons. 2. The ailment for which hospitalization is sought is not covered under u the particular insurance policy or is a part of an Exclusion under the t policy guidelines. 3. The insured has already exhausted his insurance coverage for the year.

17 Claim Process If there is an EMERGENCY Contact our call centre and inform them about the nature of emergency If possible, always go to a network hospital If not, then go to the nearest hospital In a network hospital, the patient can be admitted by showing the e FGH Wellness Card only After admission, the pre authorization has to be done

18 Claim Process If there is an EMERGENCY Our doctors will inform you and the hospital if cashless can be given The hospital will ask you for a deposit if we deny cashless If you have gone to a non network hospital, keep our call centre informed

19 Remember Cashless facility is always subject to the broader policy guidelines ines and relevant terms and conditions. Important Please note that decline of a request for Cashless Hospitalization on is only denial of Cashless Service and is in no way to be treated as denial of treatment or claim. The insured retains the right to get treated and submit the bills to FGH for subsequent Reimbursement.

20 Preliminary scrutiny of claim & verification : - Policy Benefit - Date of Loss - Mandatory Documents Claim documents received from Insured member Deficient (Some Document required For Admissibility) Repudiated (Not falling with policy conditions) Approved (Admissible under policy) Intimation of the Deficiency is sent to the client Repudiation letter sent to client Payment cheque sent to client Reply received along with all deficient documents Reply not received Subsequent reminders sent at fixed intervals Reimbursement Claims Process Documents not received Claim closed without payment

21 Reimbursement Claim Process - FAQs In case of Non Cashless Claims, what would be an appropriate plan of action to ensure timely reimbursement of the claim? If cashless facility is not availed, pre-authorization is denied or treatment is availed at a non-network network hospital, the insured will have to settle the bills directly with the hospital and subsequently claim reimbursement by submitting the following documents to FGH: 1. First Prescription / consultation note from the Doctor 2. The Claim Form duly signed by the claimant or family member 3. The Original Hospital Discharge Card 4. The Original Hospital Bill giving detailed break up of all expense heads mentioned in the bill

22 Reimbursement Claim Process - FAQs 5. The Money Receipt duly signed with a Revenue Stamp. 6. All Original Laboratory & Diagnostic Test Reports. E.g. X-Ray, X E.C.G, USG, MRI Scan, Haemogram etc 7. If you have purchased medicines in cash and if this has not been reflected in the hospital bill, please enclose a prescription from the doctor and the supporting medicine bill from the Chemist 8. If you have paid cash for Diagnostic or Radiology tests and it has h not been reflected in the hospital bill, please enclose a prescription from the doctor advising the tests, the actual test reports and the bill from the e diagnostic centre for the tests.

23 Reimbursement Claim Process - FAQs What are the norms for Intimation on Claims? Preliminary notice of claim with particulars relating to Name of the Insured Person / Claimant, Nature of illness / injury and Name and a Address of the attending Medical Practitioner / Hospital / Nursing home should be given to FGH. Intimation can be sent by e or Fax to our Call Centre.

24 Reimbursement Claim Process - FAQs Are there any norms related to the Hospital where treatment is sought s which are mandatory for admissibility of claims? Please ensure that the hospital / nursing home where you are contemplating treatment fulfills these criteria. 1.It has at least 15 inpatient beds; 2.It has a Doctor who is in attendance 24 hours per day; 3.It maintains daily medical records for each of its patients, 4.It is registered and licensed as a hospital or nursing home with the appropriate local authorities. Always instruct the hospital authority to mention the t Attending Doctor s and Hospital Registration No. in the hospital papers or demand for f a separate certificate on the same 5.The hospital provides a proper discharge summary, numbered bill and receipt for hospitalization expenses at the time of discharge

25 Reimbursement Claim Process - FAQs Where do I send my claim documents? You can handover claim documents at the Help Desk in your office All claims will be managed by the Claims Team located in Pune. Claims Team 2 nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad, Pune (Maharashtra) All claim payments advice shall be made within 14 working days from the date of receipt of COMPLETE documents. FGH may ask for the additional documents from the claimant if the e submitted documents are not sufficient to decide the admissibility of the claim.

26 Reimbursement Claim Process - FAQs What does FGH do with my claim documents? Your claim is assessed by our expert team and doctors who verify the documents and bills If all requirements are complete and the claim is admissible, the e claim is approved and the cheque is sent to you or your corporate If the claim is not admissible, then a Repudiation Letter is sent t to you / corporate by / courier If our team requires additional documents to process the claim, then a Document Recovery letter will be sent to you / corporate by e / courier FGH will send one intimation and two reminders at intervals of days If additional documents are not received after the second reminder er from FGH, the claim is assessed with the available documents. This could lead l to part payment or no payment at all.

27 Your Contact Points For any claim related query, hospital information, grievance, feedback edback or appreciation, please contact us on the following: Toll Free Phone No Toll Free Fax No

28 Insurance 2 nd Floor, Kant Helix Tower, Bhoir Colony, Opp Tata Motors, Chinchwad, Pune (Maharashtra)