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GMC Process & Orientation for as Consultants with Service providers.

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Presentation on theme: "GMC Process & Orientation for as Consultants with Service providers."— Presentation transcript:

1 GMC Process & Orientation for as Consultants with Service providers

2  Current hospital network spans over 450 cities.  hospitals networked across the country, 240 preferred partner network.

3 Always available Always available  We Offer 24 X 7 X 365 day functioning of ALL our offices including the ‘Nurse Line’  Easy to remember single access and single fax number across the country available at a LOCAL CALL rate at all locations apart from a Toll Free Line Talk to us : ; Fax us : Toll Free :  Response to your phone within 5 rings, no attachment of IVR system, attended to personally by a trained personnel  / On line web chat with us through our website at any timewww.ghpltpa.com  75% of the customer interaction issues resolved at within first call (complete scanned document management system)  Every service call or is recorded at our office for tracking purposes  Claim filing on the internet – GHPL Help Desk to scan and upload all documents from your office and generate ‘Claim Control Number’ Can be called from any network including mobiles Auto ticket no. for every mail

4  Smooth Hospitalization  Pre-arrangements done at all times in case of ‘planned’ hospitalizations  Live web-chat with customer service team through the website and call center  10 day Reimbursement Claim processing promise  Other TATs  Emergency cases – first response 30 minutes  E-cards – 48 hrs  Pre-authorization – 2-4 hours  Reimbursement claim – first response within 72 hours  Any other query Response – first response within 24 hours Dependent on the Case to Case, Accidents cases may get delayed

5  Staff  Who all are covered – Floater Basis  Self, Spouse, 2 Dependent Children – 2 Dependent Parents  Policy Coverage's  Sum Insured Rs.2 lac Family Floater  Pre Existing Diseases are Covered  Coverage from Date of Joining  30 Days waiting period is waived. Further, 1st, 2 nd, 3 rd and 4th year exclusions are waived.  MATERNITY- Maternity covered without a waiting period of 9 months..  Admissibility for Maternity claims restricted to Rs.25,000 for normal & 35,000 for C Section  New born covered from Date of Birth within the overall family floater SI and also subject to family size not exceeding stipulated as above on inclusion of the child  Room rent capped to 1% per day & ICU capped to 2% of Sum Insured  Pre 30 days and Post 60 days hospitalization covered to the max of 10% of Sum Insured - except Maternity  10% Co-Pay on all admissible claims  Cataract admissibility capped to INR 20,000 per eye  Day care procedure covered – Any new medical procedure or drugs that replace less than 24 hours hospitalization to be included as day care procedure, including animal bites treatments e.g. Dog, Snake bites  CLAIMS SUBMISSION All supporting documents relating to the claim must be submitted to the TPA within 21 days from date of discharge Ensure you Declare all your dependants

6 Room Rent and Boarding Limited to a 1% of Sum Insured for Normal Hospitalization and 2% of Sum Insured for ICU Hospitalization. Should you opt for a room of a higher category or rate, you are responsible for bearing the additional proportional charges associated with such room. Room Rent

7  Cashless  Planned Treatment or Hospitalization  Approach Network Hospital’s Insurance Desk & Fill PreAuth Form  For Planned Hospitalization request 48 hours prior to admission  Emergency Hospitalization  Approach nearest Hospital, if in network, fill PreAuth Form  If Non-Network, Pay Up front and collect All Documents * in Original  Reimbursement  Claims  Submission Original Documents with 30 Days from date of Discharge  Ensure to submit Original Documents as per the list*  Claim will be processed and settled as per Terms & Conditions of the Policy  Query in Claims  Within 5 workings days GHPL shall intimate shortfall in claim docs by raising a query  Pre & Post Hospitalization Claims  30 Days preceding date of Hospitalization, excluding maternity  60 Days succeeding Date of Discharge  The Total admissible amount is max to 10% of sum insured per hospitalization * Detailed list in next slide All Documents to be submitted in Originals Updated list available at

8  Cashless  Documents required  GHPL eCard –  Employee ID –  Govt. issued any Photo ID cards –  Reimbursement  Documents required  Claim Form  Original detailed discharge summary  Original Hospital Bill with Detailed or Itemized Break-Up  Cash paid receipts  Incase of surgical packages – detail breakup of the package  Medicine bills with prescriptions  Original investigation reports, MRI/X-Ray/CT Scan Reports  MLC or ARC from the hospital in the case of Road Traffic Accident  Obstetrics History (Gravida Details) in the case of maternity claims  Copy of GHPL ID / Copy of Patient’s Photo ID  Pre & Post Hospitalization Claims  Except for Maternity – As Maternity is not have pre-post coverage  Original investigation reports along with bills & receipts  Consultation receipts & Prescriptions  Medicine bills with prescriptions Ensure you sign the bills at Discharge

9  Treatment Covered under Day Care To name few,  Treatment Covered under Day Care - To name few,  Appendectomy  Heamo dialysis  Coronary angiography  Hydrocele  Coronary angioplasty  Hysterectomy  Colonoscopy  Parental chemotherapy  Inguinal/ventral/ umbilical/femoral hernia  D&C  Eye surgery  Piles/ fistula  Sclerotherapy  Prostrate  Radiotherapy  Sinusitis  Lithotripsy  Tonsillectomy  Incision and drainage of abscess  Liver aspiration Cashless can be availed for this list

10  General Exclusions under policy, to name few  Circumcision unless necessary for treatment  Vaccination / Inoculation  Correction of Eyesight  Cosmetic / Plastic Surgeries  Spectacles, Contact lens, Hearing aids  Dental treatment unless arising from Accident  Debility, Obesity, Psychiatric, Psycho somatic  Infertility, Sterilization, Venereal diseases  Vitamins and Tonics  Alcohol / Drug Intoxication  Maternity expenses for third delivery, Voluntary termination of Pregnancy  Genetic Disorders  STD  Naturopathy / Magnetic / Acupuncture / Other experimental therapies  Hospitalization less than 24 hours  Non Medicals, Administration Charges  Congenital External Disease  Suicide / Homicidal attempt  Alternative Medicines  Admission primarily for Investigation / Observation / Evaluation without active line of management Claims are not admissible for this list

11 Please save GHPL #  Do’s  Carry your ID card/ E-Card at the time of admission at network hospitals  In case of emergency admission, kindly contact GHPL within 24 hrs of hospitalization  In case of emergency, kindly refer our Company’s name and your Employee ID (number) at the time of admission  Take a pre-approval from GHPL for elective cases. Sign on the claim form / final bill at the time of discharge from the hospital.  Kindly ensure submission of claims within 30 days from date of Discharge from Hospital  Don’ts  Avoid a hospital with less than 15 bed capacity.  Avoid requesting for Pre-Authorization approval in 1 or 2 hours.  Avoid Domiciliary hospitalization, it is not covered.  Do not leave any bill / receipt uncollected from the hospitalization.  Avoid any mid-term inclusions of dependents except new born and spouse

12 Please check Your room rent  Please Remember  Hospitalization for Evaluation/Diagnostic purpose is not payable  Expenses for Investigation/Treatment irrelevant to the disease for which admitted or Diagnosed are not payable  Room Rent Eligibility :- Rs.2000/- for Normal Hospitalization & Rs.4000/- for ICU Hospitalization per day  Higher Side Room Rent Implication :- Rooms on higher category chosen by the Claimant and any revision in Cost of Medicals resulting from higher category opted for will borne by the Claimant. There will be proportionate deductions.  OPD is not covered, it does not fall under Day Care Procedures,  Day Care Procedures are defined by Insurance company

13 Reach us out – we will be there to address the need Yuvaraj G Swapnendu Das K Saiprasad

14 Reach us out – we will be there to address the need Anand Kumar M Krishnamurthy R B – Mgr CRM Krishnamurthy’s Mobile Dr. Navya – Manager Dr. Navya' Mobile

15 Thank You


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