Reference is invited to clause 4 of the Circular ref: IRDA/TPA/REG/CIR/059/03/2016 dated 28.03.2016 issued under the provisions of IRDAI (TPA – Health Services) Regulations, 2016. Annexure 30 of the within referred circular prescribed three claim forms namely; Part A, Part B and Part C.
In partial modification of Part C (request for cashless hospitalization for Health Insurance policy), the revised “Part C” is herewith specified.
Part D – Cashless Authorization letter Format is now introduced for issuing to the Network Providers at time of authorizing the cashless treatment. All the Insurers and the TPAs shall ensure that every network provider is notified about the cashless authorization in Part – D specified and a copy of Part D is also simultaneously notified to the policyholder/claimant to enable the policyholder / claimant have information about the package rates agreed with the network provider or the extent of authorization issued to the network provider and related conditions thereof. As and when any supplementary / additional authorization or final approval is issued and notified to the network provider, copy of Part – D shall be also invariably notified to the policyholder.
Insurers and TPAs may endeavor to obtain PART-C from the hospitals by electronic / digital means for seamless processing of the cashless requests.
Insurers and TPAs may also endeavor to notify Part – D to the network providers and the policyholders through system generated form and may specify accordingly, wherever may be the case.
All Insurers and TPAs shall ensure that the font size of these forms is not less than Times New Roman 10 and shall be clear and legible.
Insurers and TPAs may capture details of Part – C and Part – D in Optical Character recognition (OCR) / Machine readable format.
The Insurer and TPAs may specify any additional terms in Part – D subject to the Service Level Agreement entered with the network provider.
This Circular would come into effect from 1st July, 2019
