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    Claim Form - Part B Hospital

    Uploaded by

    grajesh45
    The document is a claim form to be filled out by a hospital, containing sections for details of the hospital, patient, diagnosis, procedures, pre-authorization, injury details if applicable, claim documents submitted, and details for non-network hospitals. It includes fields for names, dates, codes, facilities and a declaration requiring a signature and date. The form collects essential information needed to process an insurance claim for a patient's hospitalization.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Claim Form - Part B Hospital

    Uploaded by

    grajesh45
    721 views2 pages
    The document is a claim form to be filled out by a hospital, containing sections for details of the hospital, patient, diagnosis, procedures, pre-authorization, injury details if applicable, claim documents submitted, and details for non-network hospitals. It includes fields for names, dates, codes, facilities and a declaration requiring a signature and date. The form collects essential information needed to process an insurance claim for a patient's hospitalization.

    Original Description:

    Claim form for insurance

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    © © All Rights Reserved

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    The document is a claim form to be filled out by a hospital, containing sections for details of the hospital, patient, diagnosis, procedures, pre-authorization, injury details if applicable, claim documents submitted, and details for non-network hospitals. It includes fields for names, dates, codes, facilities and a declaration requiring a signature and date. The form collects essential information needed to process an insurance claim for a patient's hospitalization.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    721 views2 pages

    Claim Form - Part B Hospital

    Uploaded by

    grajesh45
    The document is a claim form to be filled out by a hospital, containing sections for details of the hospital, patient, diagnosis, procedures, pre-authorization, injury details if applicable, claim documents submitted, and details for non-network hospitals. It includes fields for names, dates, codes, facilities and a declaration requiring a signature and date. The form collects essential information needed to process an insurance claim for a patient's hospitalization.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    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 include the original preauthorization request form in lieu of PART A

    (To be Filled in block letters)

    DETAILS OF HOSPITAL
    a) Name of the hospital:

    e) Qualification:

    Network :
    R

    Non Network :

    (if non network fill section E)

    f) Registration No. with State Code:

    SECTION A

    c) Type of Hospital:

    a) Hospital ID:
    c) Name of the treating doctor:

    e) Date of birth: D

    g) Phone No.

    DETAILS OF THE PATIENT ADMITTED


    S

    a) Name of the Patient:

    c) Gender:
    D

    f) Date of Admission:
    j) Type of Admission:

    Emergency

    I) Status at time of discharge:

    Planned

    Discharge to home

    g) Time:

    Day Care

    Male
    H

    Female

    d) Age: Years

    h) Date of Discharge:

    i) Date of Delivery:

    k) If Maternity

    Maternity

    Discharge to another hospital

    Months M

    Deceased

    ii) Gravida Status: :

    SECTION B

    b) IP Registration Number:

    m) Total claimed amount

    DETAILS OF AILMENT DIAGNOSED (PRIMARY)


    ICD 10 Codes

    a)

    ICD 10 PCS

    b)

    Description

    i. Procedure 1:

    ii. Additional Diagnosis:

    ii. Procedure 2:

    iii. Co-morbidities:

    iii. Procedure 3:

    iv. Co-morbidities:

    iv. Details of Procedure:

    c) Pre-authorization obtained:

    Yes

    No

    Description

    SECTION C

    I. Primary Diagnosis

    d) Pre-authorization Number:

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


    Yes

    f) Hospitalization due to injury:

    No

    I. If Yes, give cause

    Self-inflicted

    ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:
    v. FIR No.

    Yes

    Substance abuse / alcohol consumption

    Road Traffic Accident


    No (If Yes, attach reports)

    iii. If Medico legal:

    Yes

    No

    iv. Reported to Police

    Yes

    ii. ICU

    Yes

    No

    vi. If not reported to police give reason:

    CLAIM DOCUMENTS SUBMITTED - CHECK LIST


    Investigation reports

    Original Pre-authorization request

    CT/MR/USG/HPE investigation reports

    Copy of the Pre-authorization approval letter

    Doctors reference slip for investigation

    Copy of Photo ID Card of patient Verified by hospital

    ECG

    Hospital Discharge summary

    Pharmacy bills

    Operation Theatre Notes

    MLC reports & Police FIR

    Hospital main bill

    Original death summary from hospital where applicable

    Hospital break-up bill

    Any other, please specify

    DETAILS IN CASE OF NON NETWORK HOSPITAL

    SECTION D

    Claim Form duly signed

    (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

    a) Address of the Hospital

    State:

    Pin Code:

    c) Registration No. with State Code:

    b) Phone No.

    d) Hospital PAN:

    e) Number of inpatient beds

    f) Facilities available in the hospital

    i. OT

    Yes

    No

    No

    SECTION E

    City:

    iii. Others:

    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.

    Place:

    SECTION F

    Date:

    Y
    Signature and Seal of the Hospital Authority:

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

    DESCRIPTION

    DATA ELEMENT

    SECTION A - DETAILS OF HOSPITAL


    a)

    Name of the hospital:

    Enter the name of hospital

    Name of the hospital in full

    b)

    Hospital ID

    Enter ID number of hospital

    As allocated by the TPA

    c)

    Type of Hospital

    Indicate whether in network or non network hospital

    Tick the right option

    Name of treating doctor

    Enter the name of the treating doctor

    Name of doctor in full

    e)

    Qualification

    Enter the qualification of the treating doctor

    Abbreviations of educational qualifications

    f)

    Registration No. with State Code

    Enter the registration number of the doctor along with the state code

    As allocated by the Medical Council of India

    g)

    Phone No.

    Enter the phone number of doctor

    Include STD code with telephone number

    c)

    SECTION B - DETAILS OF THE PATIENT ADMITTED


    a)

    Name of Patient

    Enter the name of patient

    Name of patient in full

    b)

    IP registration Number

    Enter insurance provider registration number

    As allotted by the insurance provider

    c)

    Gender

    Indicate Gender of the patient

    Tick Male or Female

    d)

    Age

    Enter age of the patient

    Number of years and months

    e)

    Date of Birth

    Enter date of birth

    Use dd-mm-yy format

    f)

    Date of Admission

    Enter date of admission

    Use dd-mm-yy format

    g)

    Time

    Enter Time of admission

    Use hh:mm format

    h)

    Date of Discharge

    Enter date of Discharge

    Use dd-mm-yy format

    i)

    Time

    Enter time of Discharge

    Use hh:mm format

    j)

    Type of Admission

    Indicate type of admission of patient

    Tick the right option

    k)

    If Maternity
    Date of Delivery

    Enter Date of Delivery if maternity

    Use dd-mm-yy format

    Gravida Status

    Enter Gravida status if maternity

    Use standard format

    Status at time of discharge

    Indicate status of patient at time of discharge

    Tick the right option

    Indicate the total claimed amount

    In rupees (Do not enter paise values)

    l)
    M)

    Total claimed amount

    SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)


    a)

    ICD 10 Code
    Primary Diagnosis

    Enter the ICD 10 Code and description of the primary diagnosis

    Standard Format and Open text

    Additional Diagnosis

    Enter the ICD 10 Code and description of the additional diagnosis

    Standard Format and Open text

    Co-morbidities

    Enter the ICD 10 Code and description of the Co-morbidities

    Standard Format and Open text

    Procedure 1

    Enter the ICD 10 Code and description of the first procedure

    Standard Format and Open text

    Procedure 2

    Enter the ICD 10 Code and description of the second procedure

    Standard Format and Open text

    Procedure 3

    Enter the ICD 10 Code and description of the third procedure

    Standard Format and Open text

    Details of Procedure

    Enter the details of the procedure

    Open text

    c)

    Pre-authorization obtained

    Indicate whether pre-authorization obtained

    Tick Yes or No

    d)

    Pre-authorization Number

    Enter pre-authorization number

    As allotted by TPA

    e)

    If authorization by network hospital not obtained, give reason

    Enter reason for not obtaining pre-authorization number

    Open text

    b)

    f)

    ICD 10 PCS

    Hospitalization due to injury

    Indicate if hospitalization is due to injury

    Tick Yes or No

    Cause

    Indicate cause of injury

    Tick the right option

    If injury due to substance abuse/alcohol consumption test


    conducted to establish this

    Indicate whether test conducted

    Tick Yes or No

    Medico Legal
    Reported to Police

    Indicate whether injury is medico legal

    Tick Yes or No

    Indicate whether police report was filed

    Tick Yes or No

    FIR No.

    Enter first information report number

    As issued by police authorities

    If not reported to police, give reason

    Enter reason for not reporting to police

    Open text

    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

    Include Street, City and Pin Code

    b)

    Phone No.

    Enter the phone number of hospital

    Include STD code with telephone number

    c)

    Registration No. with State Code

    Enter the registration number of the Hospital obtained from local body
    like City Corporation / Municipality

    As allocated by the City Corporation / Municipality

    d)

    Hospital PAN

    Enter the permanent account number

    As allocated by the Income Tax Department

    e)

    Number of Inpatient beds

    Enter the number of inpatient beds

    Digits

    f)

    Facilities available in the hospital

    Indicate facilities available in the hospital

    Tick the right option. If others, please specify

    SECTION F - DECLARATION BY THE HOSPITAL


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

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