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What is TPA?

  • The Third Party Administrator is a service through which a policy holder can seek cashless facility from Kokilaben Dhirubhai Ambani Hospital.
  • Please contact the TPA desk located on the Ground floor lobby, prior to your admission to understand the TPA process.

What are the documents required for the cashless process?

Please get the photocopies of the following documents for your convenience:

  • Past 3 years of Policy papers
  • TPA card
  • PAN Card
  • Aadhar Card
  • Latest passport size photograph
  • Doctor’s Consultation letter
  • Relevant Investigation Reports
  • Employee Id (If corporate policy)

What to expect out of the cashless facility?

In case of a planned admission, a prior approval from your TPA is a must to avail the cashless facility.

In case of emergency/unplanned admission, the patient will need to pay the requisite deposit amount and then seek approval from the TPA

Please note the cashless facility is subject to the terms and conditions applicable in the policy.

The hospital is not responsible for the refusal /denial/partial approval on the part of the TPA for cashless/reimbursement of claims made by the patient.

Patient hereby would have to clear all the hospital bills (before discharge):-

a. In the event that the insurance claim i.e. the cashless facility is fully denied

b. If partial payment approval is received from the insurance company

c. For the payment of non medical items ( 5 %  Security Deposit )

d. For the higher package voluntarily opted by patient/patient relative

e. For equipment charges / consumables not covered by the insurance company

What are GIPSA packages?

Kokilaben Dhirubhai Ambani Hospital currently offers agreed surgical packages at special GIPSA (General Insurance Public Sector Association)ratesto patients covered under Public Sector Undertaking Insurance Companies listed below:

a)  National Insurance Company Ltd

b)  New India Assurance Company Ltd

c)  Oriental Insurance Company Ltd

d)  United India Insurance Company Ltd

Please contact the Hospital TPA desk for further details on the packages.

Emergency charges are applicable to patients admitted on Public Holidays, Sundays & during emergency hour admission i.e. from 8:00 PM to 8:00 AM

What is the procedure for availing TPA service?

Before Admission:

  • Pre –Authorization-The patient /relative needs to get the pre auth form filled by the treating doctor.
  • The documents and the dully filled pre-authorization form are to be submitted to the TPA via email.
  • On receipt of the details the TPA sends either-an approval or a query is raised.
  • Once the approval is received the patients/relative is informed about the same. In case of query –The TPA desk helps patient to respond to the query with help of doctors and get the case approved.
  • In case where part approval is received or certain conditions are highlighted by the TPA the same is conveyed /explained to the patient/relative.
  • OPD procedures and Radiation will not be considered for cashless in the hospital and need to be reimbursed as per hospital policy.
  • Pre-Authorization for daycare patients will not be accepted on the day of the procedure.

On Admission:

  • The patient gets admitted by paying 5% security deposit and the balance deposit amount (in case where partial approval is received)
  • In case where the patient declares the insurance status at the time of admission, the admission is done by collecting deposit amount and the patient is directed to the TPA desk to complete the TPA formalities. This process can be done by the relative. On receipt of the approval the same is applied to the patient’s “In-patient account”
  • In situation where the patient has applied for the TPA approval however no reply /approval has been received by the hospital, then the patient gets admitted by paying the full requisite deposit.
  • Interim Approvals: For long stay patients-Interim bills are forwarded to the TPA for enhancement. Response received from the TPA in the form of Approval or Query is then applied or responded back.

At Discharge:

  • The final bill and the discharge summary are forwarded to the TPA for the final approval once the patient is for discharge.
  • There can be query at the time of discharge because of which the discharge can get delayed.
  • The time taken for the final approval to be received by hospital maybe in range of 1 to 5 hrs (approx) depending on the case. In case the patient wishes to take discharge before the approval arrives, the same can be done by settling the bill. The patient could then claim from the TPA directly. The patient must wait for final approval even if the sum insured exhausted.
  • TPA formalities cannot be started on the day of discharge.

Some More information:

1. Non medical expenditures, room rent capping & copayment applies to certain cases. Kindly understand the same before the admission.

2. Room rent is applicable on the day of discharge.

3. The deposit amount (if any) paid by the patient will be refunded within 8 days after discharge. The refunded amount is always by cheque if it is more than Rs 10,000/-

4. The security deposit is refunded once the approved amount is received by the hospital from the TPA / Insurance.

5. Deductions by TPA after the approval is given (Post Discharge) - Incase the TPA/Insurance does not pay the approved amount ; the balance outstanding is settled with the security deposit. This stands valid for any emergency charges levied on the bill.

6. The hospital is not responsible for the refusal /denial on the part of the TPA for reimbursement of claims made by the patient.

7. The original reports and the discharge summary will be handed over to the TPA/Insurance Company.

8. Admission in the hospital is subject to the availability of the bed.

9. The hospital authority is entitled to share data/records related to admission with representatives/agents from the Insurance Company, TPA or employer.

10. Emergency charges are applicable to patients admitted on Public Holidays, Sundays & during emergency hour admission i.e. from 8:00 PM to 8:00 AM

Kindly contact us on: Ph 9022263999 (11 am to 5 pm) Email: tpa.kh@relianceada.com

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