Steps of claim process

Question

Accepted Answer

The claim process involves several steps to ensure accurate and timely resolution.

1. Claim submission: The policyholder submits a claim to the insurance company, providing all necessary documentation.
2. Claim review: The insurance company reviews the claim to determine its validity and coverage.
3. Investigation: If required, the insurance company investigates the claim further, gathering additional information or evidence.
4. Claim assessment: The insurance company assesses the claim based on policy terms, coverage limits, and applicable laws.
5. Claim decision: The insurance company makes a decision on the claim, either approving or denying it.
6. Claim payment: If approved, the insurance company processes the payment to the policyholder or the service provider.
7. Claim closure: Once the payment is made, the claim is closed, and all necessary documentation is filed for record-keeping.
8. Claim appeal: If the claim is denied, the policyholder may have the option to appeal the decision and provide additional information or arguments.
9. Claim settlement: In some cases, the insurance company and the policyholder may negotiate a settlement to resolve the claim.
10. Claim recovery: If the insurance company pays the claim, they may seek recovery from responsible third parties or subrogation if applicable.

Accepted Answer

1. Initiate pre authorisation request to insurance/TPA company And wait for response from insurance/TPA side.
2. Check the company response if calim approved than wait for discharge and send the final Authorization request to insurance/TPA company. And if company raise any query regarding the claim than we have to reply the query 1st and again wt for approval.
3. After receiving pre authorisation, we will send final Authorization request at the time of discharge for final Authorization approval. Than wt for company revert and after recieved the company approval, we can discharge the pt.
4. After discharge the pt., We have to send all original claim documents to insurance/TPA company to process the claim and it's settled to hospital designated account.

Steps of claim process

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