Sample Claim Form Part B

SECTION A

DETAILS OF HOSPITAL a) Name of the hospital: b) Hospital ID: d) Name of the treating doctor:

SAMPLE CLAIM FORM PART B – REIMBURSEMENT
Form to be filled in by the hospital in concern
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issue of this Form is not to be taken as an admission of liability Please indude the original preauthorization request form in lieu of PART A

(To be filled in block letters)

c) Type of Hospital:

S U R N A ME

F

Network I R S T

Non Network N A ME

(If non network fill section E)

M I D D LE

N A ME

e) Qualification: DETAILS OF THE PATIENT ADMITTED

f) Registration No. with State Code:

g) Phone No.

a) Name of the Patient:

S U R N A ME

F IRST

N A ME

M I D D LE

N A ME

b) IP Registration Number

c) Gender: Male Female

d) Age: Years

Months

e) Date of birth: D D M M

f) Date of Admission: D D M M

g)Time: H H M M

h) Date of Discharge: D D M M

i)Time: H H M M

j) Type of Admission: Emergency Planned Day Care Maternity

k) If Maternity i. Date of Delivery: D D M M

ii. Gravida Status:

l) Status at time of discharge: Discharge to home

Discharge to another hospital

Deceased

m) Total claimed amount:

SECTION B

SECTION C

SECTION D

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a)

ICD10 Codes

Description

i. Primary Diagnosis: ii. Additional Diagnosis: iii. Co-morbidities: iv. Co-morbidities:

b)
i. Procedure1: ii. Procedure2: iii. Procedure3: iv. Details of Procedure:

ICD 10 PCS

Description

c) Pre-authorization obtained:

Yes No

d) Pre-authorization Number:

e)if authorization by network hospital not obtained, give reason:

f) Hospitalization due to Injury: Yes No i. If Yes, give cause Self-inflicted

Road Traffic Accident

Substance abuse / alcohol consumption

ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: Yes No (If Yes, attach reports)

iii. If Medico legal: Yes No iv. Reported to Police: Yes No vi. If not reported to police give reason:

v. FIR no.

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Original Pre-authorization request Copy of the Pre-authorization approval letter Copy of photo ID card of patient verified by hospital Hospital Discharge summary Operation Theater notes Hospital main bill Hospital break-up bill

Investigation reports CT/MR/USG/HPE investigation reports Doctor’s reference slip for investigation ECG Pharmacy bills MLC report & Police FIR Original death summary from hospital where applicable Any other, please specify

DETAILS IN CASE OF NON NETWORK HOSPITAL

(ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the hospital:

d) Hospital PAN: iii. Others:

City: Pin Code:

b)Phone No. e) No of Inpatient beds

State: c) Registration No. with State Code: f) Facilities available in the hospital: i.OT: Yes No ii. ICU: Yes No

DECLARATION BY THE HOSPITAL

(PLEASE READ VERY CAREFULLY)

We 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 forfeited.

Date: D D Place:

M M

Signature and Seal of the Hospital Authority:

SECTION E

SECTION F

GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)

DATA ELEMENT

DESCRIPTION

SECTION A - DETAILS OF HOSPITAL

a) Name of Hospital

Enter the name of hospital

b) Hospital ID

Enter ID number of hospital

c) Type of Hospital

Indicate whether In network or non network hospital

d) Name of treating doctor

Enter the name of the treating doctor

e) Qualification f) Registration No. with State Code g) Phone No.

Enter the qualifications of the treating doctor Enter the registration number of the doctor along with the state code Enter the phone number of doctor

SECTION B - DETAILS OF THE PATIENT ADMITTED

a) Name of Patient

Enter the name of hospital

b) IP Registration Number

Enter insurance provider registration number

c) Gender

Indicate Gender of the patient

d) Age

Enter age of the patient

e) Date of Birth

Enter date of admission

f) Date of Admission

Enter date of admission

g) Time

Enter time of admission

h) Date of Discharge

Enter date of discharge

i) Time

Enter time of discharge

j) Type of Admission

Indicate type of admission of patient

k) If Maternity

Date of Delivery

Enter Date of Delivery if maternity

Gravida Status

Enter Gravida status if maternity

1) Status at time of discharge

Indicate status of patient at time of discharge

m) Total claimed amount

Indicate the total claimed amount

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code Primary Diagnosis Additional Diagnosis Co-morbidities

Enter the ICD 10 Code and description of the primary diagnosis Enter the ICD 10 Code and description of the additional diagnosis
Enter the ICD 10 Code and description of the co-morbidities

b) ICD 10 PCS

Procedure 1

Enter the ICD 10 PCS and description of the first procedure

Procedure 2

Enter the ICD 10 PCS and description of the second procedure

Procedure 3

Enter the ICD 10 PCS and description of the third procedure

Details of Procedure

Enter the details of the procedure

c) Pre-authorization obtained

Indicate whether pre-authorization obtained

d) Pre-authorization Number e) If authorization by network hospital not obtained, give
reason f) Hospitalization due to injury

Enter pre-authorization number Enter reason for not obtaining pre-authorization number Indicate if hospitalization is due to injury

Cause If injury due to substance abuse/alcohol consumption, test conducted to establish this
Medico Legal

Indicate cause of injury Indicate whether test conducted Indicate whether injury is medico legal

Reported To Police

Indicate whether police report was filed

FIR No.

Enter first information report number

If not reported to police, give reason

Enter reason for not reporting to police

SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted

SECTION E- DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address

Enter the full postal address

b) Phone No. c) Registration No. with State Code d) Hospital PAN

Enter the phone number of hospital Enter the registration number of the doctor along with the state code Enter the permanent account number

e) Number of Inpatient beds

Enter the number of inpatient beds

f) Facilities available in the hospital

Indicate facilities available in the hospital

SECTION F - DECLARATION BY THE HOSPITAL

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

FORMAT
Name of hospital in full As allocated by the TPA Tick the right option Name of doctor in full Abbreviations of educational qualifications As allocated by the Medical Council of India Include STD code with telephone number
Name of hospital in full As allotted by the insurance provider Tick Male or Female Number of years and months Use dd-mm-yy format Use dd-mm-yy format Use hh:mm format Use dd-mm-yy format Use hh:mm format Tick the right option
Use dd-mm-yy format Use standard format Tick the right option In rupees (Do not enter paise values)
Standard Format and Open text Standard Format and Open text Standard Format and Open text
Standard Format and Open text Standard Format and Open text Standard Format and Open text Open text Tick Yes or No As allotted by TPA Open text Tick Yes or No Tick the right option Tick Yes or No Tick Yes or No Tick Yes or No As issued by police authorities Open Text
Include Street, City and Pin Code Include STD code with telephone number As allocated by the Medical Council of India As allotted by the Income Tax department Digits Tick the right option. If others, please specify