How to Claim Mediclaim: Cashless & Reimbursement

A health insurance claim is a formal request for payment that a healthcare provider or policyholder submits to an insurance company for medical services received. Understanding this process is important for managing healthcare expenses and utilizing health coverage effectively.

Understanding Claim Types

Health insurance claims primarily fall into two categories: cashless claims and reimbursement claims.

A cashless claim allows a policyholder to receive medical treatment at a network hospital without paying upfront for covered services. The hospital directly coordinates with the insurance company to settle the bill, reducing the immediate financial burden on the patient. This method is typically used for planned treatments or emergencies at facilities within the insurer’s network.

Conversely, a reimbursement claim involves the policyholder paying for medical services out-of-pocket first. After treatment, the policyholder submits a claim to their insurance company with all supporting documents for reimbursement. This type of claim is often utilized when receiving care from out-of-network providers or in emergency situations where a network hospital is not accessible.

Gathering Claim Documents

Accurate and complete documentation is crucial for both cashless and reimbursement claims. Policyholders should always retain their health insurance policy documents and identification proof. These items establish coverage and verify the patient’s identity.

Medical records provide essential details about the treatment received. This includes a medical certificate from the doctor, diagnostic reports, and the discharge summary from the hospital. The discharge summary is particularly important as it details the patient’s hospitalization, diagnosis, treatment, and condition upon release, serving as proof of hospitalization.

Detailed financial records, such as itemized hospital bills, pharmacy bills, and receipts for any investigations or consultations, are also necessary. An itemized bill provides a line-by-line breakdown of all services, procedures, and medications, along with their costs and corresponding medical codes, which is essential for insurance companies to process claims accurately.

Policyholders should also include original prescriptions from the attending physician. For claims arising from accidents, a police report or Medico-Legal Certificate (MLC) may be required. Before submission, complete any necessary claim forms accurately, ensuring all personal and medical information aligns with the supporting documents.

Cashless Claim Process

Initiating a cashless health insurance claim begins with notifying the insurer or their Third-Party Administrator (TPA) about a planned hospitalization in advance. In an emergency, notification should occur as soon as possible after admission.

Upon admission to a network hospital, the policyholder presents their health insurance card and identification. The hospital assists in completing a pre-authorization form, detailing the proposed treatment and estimated costs. This form, along with supporting medical documents, is submitted by the hospital to the insurer or TPA for approval.

The insurer reviews the pre-authorization request, assessing it against the policy’s terms and conditions, including coverage limits and medical necessity. If approved, the insurance company communicates its decision and the approved amount to the hospital. The hospital then directly settles the covered medical bills with the insurer, with the policyholder only responsible for non-covered expenses, deductibles, or co-payments at the time of discharge.

Reimbursement Claim Process

The reimbursement claim process requires the policyholder to initially cover all medical expenses incurred. After receiving treatment, collect all original documents, including detailed itemized bills, discharge summaries, and medical reports.

The policyholder then needs to obtain and accurately complete the claim form provided by their insurance company. This form requires personal details, policy information, and specifics about the medical treatment and expenses.

Once all necessary documents are gathered and the claim form is filled out, the complete package is submitted to the insurance company or its TPA. Submission methods can include mail, online portals, or in-person delivery. Timely submission is important, with typical deadlines ranging from 90 days to one year from the date of service, though this can vary by insurer and policy.

After Claim Submission

After a health insurance claim is submitted, policyholders can track its status through the insurer’s online portal or by contacting customer service. Initial verification often occurs within a few days, followed by a thorough assessment of medical documents and bills.

Insurance companies generally process electronic claims within 7 to 14 days, while paper claims may take 30 to 45 days. During this period, the insurer may request additional information or clarification. Once processed, the policyholder receives an Explanation of Benefits (EOB), which details how the claim was paid, the amount covered by insurance, and any remaining balance owed.

If a claim is denied, policyholders have the right to appeal. The insurer must provide a written explanation for the denial and information on how to dispute it. Policyholders can initiate an internal appeal with their insurance company, and if still unsatisfied, may pursue an external review by an independent third party.