actiance india private limited - fhpl · advantageously to assist actiance india private limited in...
TRANSCRIPT
TPA Services
For
Actiance India Private
Limited
Bangalore
Limited
By
Family Health Plan Limited
Core competence of FHPL is healthcare administration and is placed advantageously to assist Actiance India Private Limited in their pursuit of delivering quality care to its enrolled members.
� Decade old experience in Indian Health Insurance
� Licensed Third Party Administrator (TPA) by IRDA ( L.No: 013)
� First ISO Certified TPA in the country
� Largest TPA offering nation wide services to over 20 million lives
About Family Health Plan Limited (FHPL)About Family Health Plan Limited (FHPL)
� Largest TPA offering nation wide services to over 20 million lives
� Only TPA to design & implement Self Funded Schemes for Govt.
� TPA with the widest network hospital spread till district level (4577)
� Pan India presence with 19 offices across the country
Benefit Details
Policy Parameter
Insurer United India Insurance Co
TPA Family Health Plan(TPA) Limited.
Policy Start Date 3rd January 2013
Policy End Date 2nd January 2014
Coverage Type Individual Sum Insured (1+5)
Dependent Coverage Yes (Spouse, two living children & Parents)Dependent Coverage Yes (Spouse, two living children & Parents)
Benefits covered
1st 30 days waiting period exclusion • Waived off
2 year exclusion • Waived off
Scope of cover • Covered from date of joining
Co Payment 80:20% co payment for each and every claim of dependents, Maximum
Payable is INR.80000/-. However no Co - Pay clause applicable for
employees.
Maternity benefits Maternity covered upto a maximum of INR 25,000/- for Normal Delivery &
INR 35,000/-Cesarean Section , well baby expenses are covered with in
Benefit Details
INR 35,000/-Cesarean Section , well baby expenses are covered with in
maternity sub limit, for any Complication baby covered from main sum
insured
9 Month Waiting Period for Maternity
Waived for all
Special Intimation ([email protected]) should be given within 24hrs of hospitalization to FHPL.
Claim document should be submitted with 15 days from the DOD from hosp, incase of post hospitalization claim document must be submitted with in 7day after completion of the relevant treatment
Definition of Hospital :
Any Hospital or Nursing home which is Registered with local authority and
has more than 15 Beds.has more than 15 Beds.
Definition of Hospitalization :
Minimum period of 24 hrs of admission in a hospital for a proper medical/
Surgical management.
•Adenoidectomy
•Appendectomy
•Ascitic/Pleural tapping
•Auroplasty
•Coronary angiography
•Coronary angioplasty
•Fracture/dislocation excluding hairline fracture
•Radiotherapy
•Lithotripsy
•Incision and drainage of abscess
•Colonoscopy
•Hydrocele
•Hysterectomy
•Inguinal/ventral/Umbilical/ Femoral Hernia
•Parenteral chemotherapy
•Polypectomy
Time Limit Not Applicable For Specific Treatments like
•Coronary angioplasty
•Dental surgery
•D&C
•Endoscopies
•Excision of Cyst/Granuloma/lump
•Eye surgery
•Colonoscopy
•Varicocelectomy
•Wound suturing
•FESS
•Haemo dialysis
•Fissurectomy / Fistulectomy
•Mastoidectomy
•Septoplasty
•Piles/ fistula
•Prostrate
•Sinusitis
•Tonsillectomy
•Liver aspiration
•Sclerotherapy
•Varicose Vein Ligation
Policy Exclusions - Diseases not covered
� Plastic Surgery (Cosmetic)
� Alcoholism related ailments� Alcoholism related ailments
� Sterility/Venereal Disease/Circumcision
� Intentional Self Injury
� AIDS
� Congenital Diseases (External) e.g. An operation to remove a 6th finger, Skin
Grafting, Convalescence / General Debility, Dental including root canal Treatment
Policy Exclusions: In-Patient Treatment not covered� Laboratory Expenses not consistent with treatment.
� Vitamins & Health Drinks like Horlicks, Complain etc and Tonic inconsistent with
treatment, Special diet and extra diet for patients (unless prescribed by the Doctor)
� Telephone, Fax, Barber, Photocopy, Vaccinations, Toiletries and TV charges
� External Implants e.g. An operation to remove a 6th finger, Skin Grafting, Supports
and Accessories, e.g. Crutchesand Accessories, e.g. Crutches
� Service Charges, Maintenance and Surcharges, Special Nursing, Attendant Pass
� Abortion done for voluntary reasons & before 12 weeks
� Food and Beverage for Relatives
� Diagnostic Expenses (only for out-patient)
� Damage done by the patient (accidentally). Damage charges not covered.
Policy Exclusions: Other Expenses not covered
� Spectacles, Contact Lens, Hearing Aid
� Use of intoxicating drugs/ alcohol
� Naturopathy
� Non Medical Items- e.g. Sanitary Pads, Diapers, Razors, Soaps, CD’s etc� Non Medical Items- e.g. Sanitary Pads, Diapers, Razors, Soaps, CD’s etc
� Admission , Documentation and MRD Charges, Registration fees, Surcharges, Services
Charges and related expenses
� Food & Beverages
� Telephone/Fax, Xerox or Certifying charges, Medical records/ Stationary expenses
� Attendant’s & Special Nursing charges, Extra Bed/ Bed retaining charges, TV/
Laundry
�
Pre-authorization Process for Cashless
Hospital sends Intimation to
FHPL
Out of Pocket
Member
approaches
Hospitals with
FHPL ID Card
Eligibility
Covered
Not
Covered
Authorization asper eligibility
Out of Pocket payment
� TAT : less than 2 hrs for routine cases
� Regularization within 24 Hrs
� Process of cashless authorisation is
decentralized
Cashless treatmentat NWH
Member avails treatment at any hospital and makes upfront payment
Member submits bills to FHPL within15 days of discharge
Protocol for Availing Treatment in Non Network Hospital
FHPL processes claimsSettle the Claim in 21 days
FHPL verifies the documents submitted
In case of incomplete documents recovery of documents for scrutiny
Procedure for Reimbursement (Non Network Hospitals)
Pay and settle the bills & collect the following documents from the hospital.
Submit the same to FHPL representative within 15 days of discharge :
1. UIIC claim form, duly filled & signed by the claimant.
2. Discharge Summary - Original.
3. Final Bill with breakup
4. Receipts for the payment made.
5. All Laboratory investigation Reports
6. In case of surgical packages – detail breakup of the package.
7. Medicine bills with prescriptions.
8. In case of maternity Gravida status to be mentioned in discharge summary.
9.In case of road accidents member needs to submit FIR copy/MLC copy
30 Days pre & 60 Days Post hospitalization.
1. UIIC claim form, duly filled & signed by the claimant.
2. Original investigation reports along with bills & receipts.
3. Consultation receipts.
4. Medicine bills with prescriptions.
Hospitalization Guidelines & Advantages
Guidelines:
Recommend you to obtain pre-authorizations at least in advance of 24 hours for all elective cases and get treated in a N etwork Hospital of FHPLFHPL
Advantages:
Simple Documentation – Sign off on discharge (Non-Me dical expenses will be borne by the member) , documents processed by FHPL directly.
Non – Network Hospitals can be used based on needs & urgency.
Call Center
� Dedicated member helpline 24 x 7
� Nationwide Toll free 1800 – 425 - 4033
� 24 X 7days accessible
� Electronically supported systems
� Managed by professionally skilled manpower� Managed by professionally skilled manpower
� Assistance in information on
� Network hospitals
� Enrollment status
� Support services in an Emergency
� Coverage eligibility
� Claims- documentation support, query handling
� General information on health plan
Query onQuery on PersonPerson MobileMobile EmailEmail
Account ManagerAccount Manager Mr. L Chandra ShekarMr. L Chandra Shekar 09243700289 [email protected]@fhpl.net
Claims & General Claims & General Queries Queries
Ms.Ms. Cynthia KavirajCynthia Kaviraj 080-22356251 / 52 [email protected]@fhpl.net
Network Hospital Network Hospital [email protected]@fhpl.net
Contact – FHPL, Bangalore
Network Hospital Network Hospital Dr. Manu SharmaDr. Manu Sharma 92434 79824
[email protected]@fhpl.net
PrePre--authorizationsauthorizations Dr. Kiran / Mr. RaviDr. Kiran / Mr. Ravi 080-22356251 / 52 [email protected]@fhpl.net
Any Escalations on Any Escalations on the abovethe above
Mr. Ramalinga ReddyMr. Ramalinga Reddy 092434 [email protected]@fhpl.net
FHPL Address
Family Health Plan (TPA) Ltd
No.11,2nd Floor E Block No.11,2nd Floor E Block
NITON Palace Road
Bangalore. – 560 052
Ph: 080 – 22356256 / 57
Fax: 080 – 22356255
THANK YOU THANK YOU