Patient Initiates the Claim:

When a policyholder seeks medical treatment in a network hospital or healthcare provider, they initiate the claim by providing the necessary documents, such as:

Medical prescriptions and reports

Pre-authorization forms (for planned treatments)

Details of hospitalization or outpatient treatments

Proof of identity and policy details

Pre-Authorization (Before Treatment)

Request for Cashless Authorization: Before non-emergency treatments, the insured submits a pre-authorization request to the insurance company. This is typically submitted by the hospital’s billing or insurance desk.

Verification of Policy and Eligibility: The insurer checks if the treatment is covered by the policy, whether the insured is eligible for cashless treatment, and if the hospital is part of the insurer’s network.

Medical Review: For some treatments, especially complex or high-cost procedures, the insurer may involve their medical team to assess whether the treatment is medically necessary and aligns with the policy.

Approval or Denial: Based on the assessment, the insurer either approves or denies the pre-authorization request. If approved, the hospital can proceed with the treatment, and the insurer will settle the bills directly with the hospital.

Fraud Prevention and Authentication (During Treatment)

Identity Verification: The insurer verifies the identity of the patient and checks the validity of the claim submission. This includes confirming the patient's details, policy number, and treatment type.

Monitoring Treatment: Insurers may monitor high-cost or extended treatments, including surgeries or long-term hospital stays, to ensure that the treatment is consistent with the initial diagnosis.

Medical Necessity Review: Insurers evaluate the appropriateness of the treatment based on medical necessity, which may involve consulting with medical professionals or reviewing patient records.

For example, if the treatment requested is an elective procedure or cosmetic surgery, it might not be covered.

Claim Resolution

Approval: If everything is found to be in order, the insurer approves the cashless claim and settles the amount directly with the healthcare provider.

Partial Payment: In some cases, only a portion of the claim is approved, based on policy terms (for example, co-pays or limits on certain treatments).

Denial of Claim: If the investigation reveals fraudulent or unnecessary treatments, or the claim falls outside policy coverage (like non-network hospital visits, pre-existing conditions, or excluded treatments), the insurer may deny the claim