ho control of branches -...

HO Control of Branches

S.No Activity Check Points

1 Policy collection and Enrollment

1.1

Branch to ensure weekly collection of policies from each u/w office Daily/Weekly collection report

1.2

Where soft copy is collected , branch to forward the same to HO and ensure upload

Branch to record all soft copy collections in their Monthly reports and to be reconciled with HO Enrollment deptt

1.3 Policies collected to be duly inwarded Inward Register at Branch

1.4 Enrollment Process Daily process MIS

1.5 Dispatch of Cards Card Dispatch Register

1.6 Return cards and handover to u/w office Return Card dispatch register

1.7

64 VB and Cheque bounce Register to be collected from each u/w office and to be uploaded in system 64 VB register office wise

1.8 Achievement of monthly business collection Monthly MIS

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2 2.1 Cash less Process Daily Cash less MIS

2.2 Cash less referred to HO Daily MIS of HO Pendancy

3 3.1 Claim Process Daily Claims MIS

3.2 Query Process System MIS

3.3 Claims Exception System MIS

3.4 DV Dispatch and monitoring of DV,s not received System MIS

3.5 Cheque Preparation process System MIS

3.6 Cheque Dispatch to Insured Outward Register

3.7 Float Preparation and Management

Float Register (Excel ) . Monthly Back up to HO

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4 4.1 TPA Fees Management TPA Fees Regsiter

4.2 TPA Fees Reconciliation with HO Monthly Reco Register

5 5.1 Branch Administration

5.2 Daily Attendance/Leaves

5.3 Branch Assets

5.4 Branch Stationary

5.5 Housekeeping

5.6 Statutory Dues

5.7 HR Management Monthly MIS

6 6.1 Grievance Management Grievance Register

7 7.1 CRCM/Customer Feedback CRCM Register

8 8.1 Audit by Insurance Co Action /Closure report

8.2 Internal Audit by HO Team Action /Closure report

9 9.1 Claims Investigations Investigation register

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10 10.1 External MIS Exception MIS

10.2 Internal MIS Exception MIS

11 11.1 Network Management Monthly MIS

12 12.1 Accounts and Branch Profitability Monthly MIS

13 13.1 Corporate Management

13.2 CRCM/Help Desk

13.3 Renewal Control

13.4 New Business Generation

13.5 Claims TAT Control

13.6 Grievances/Escalations Monthly MIS

14 14.1 Communications (External/Internal )

15 15.1 Systems and IT /Back up of data

16 16.1 ISO Compliances

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TAT and Process Control

S.No Deptt/Process/Activity Quality/TAT/Errors Controls/Checks

1 Business Development

1.1 Policy Pick up Weekly

1.2 Corporate Renewals 95%

1.3 64 VB/Cheque Bounce Register collection Monthly

2 Enrollment & Dispatch

2.1 Proposer Entry 24 hrs

2.2 Enrollment & Dispatch 7 days

2.3 Cards Correction 48 hrs

2.4 Returned Cards Dispatch Monthly

2.5 Overall error margin 1%

3 Courier & Dispatch

3.1 Dak Entry & Distribution same day

3.2 Dispatch & Entry is system same day

3.3 POD Control Weekly

4 Claims

4.1 Filling 24 hrs System Exception

4.2 Scanning & Bill Instimation 24 hrs System Exception

4.3 Bill Entry 24 hrs System Exception

4.4 Doctor Assessment 24 hrs System Exception

4.5 Authorization 24 hrs System Exception

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Productivity Analysis

4.6 Filling 70/day Weekly MIS

4.7 Bill Intimation 60/day Weekly MIS

4.8 Scanning 200/day Weekly MIS

4.9 Bill Entry 40/day Weekly MIS

4.10 Doctor Assessment 35/day Weekly MIS

4.11 Authorization 50/day Weekly MIS

5 Finance Settlement

5.1 Audit 24 hrs Manual

5.2 Finance Settlement 24 hrs Systems TAT

5.3 Finance Authorization 24 hrs Systems TAT

5.5 BRS/Float Reconciliation Weekly Weekly MIS

5.6 Audit errors 1% Internal Audit Reports

6 Cash less Process 4-6 hrs ( Max 24 hrs) Systems TAT


7 General Finance

7.1 TPA Fees Billing Monthly/Quarterly

7.2 BRS of all Banks Monthly

7.3 Trial Closure monthly

7.4 Cash Tallying Daily

7.5 Statutory Payments/Returns

7.5.1 TDS

7.5.2 Service Tax

7.5.3 ESI

7.5.4 PF

7.5.6 Fringe Benefit Tax

7.5.7 Divident Tax

7.5.8 ROC Returns

7.5.9 IT Returns

7.5.10 Creditor Reco Monthly

7.5.11 Budgeting Annual

7.5.12 Budgetary Variance Monthly

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7.5.13 Bank Returns monthly

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8 Network Management Group

8.1 Hospital Payments 30 days

8.2 Bill Collection 15 days fm Discharge

8.3 Patient Discharge 15 days fm Authorization

8.4 Investigations 3 days

8.5 Cash less out of system weekly Reco

8.6 Hospital Reco Monthly/Quarterly

9 Grievances Redressal 7 days Systems TAT

10 MIS

9.1 Insurance Companies HO/RO/U/w office Monthly

9.2 Corporates Monthly/Quarterly

9.3 Hospitals Monthly /Quarterly

9.4 IRDA Annual

9.5 TAC Annual

9.6 Internal (HOD,s/Branches) Weekly/Monthly

11 Systems

11.1 Back Up Daily

11.2 Licensing

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Branch Manual

Index

Pages

1. Policy Pick-up & Enrollment 2 – 3 2. Cashless Process 4 – 5 3. Claim Intimation 6 4. Claim Reimbursement 6 – 7 5. Claim Reimbursement Flow Chart 8 – 9 6. MIS 10

7. Network Management 11 8. Annexures

a. Daily Collection Sheet 12 b. Corporate Enrollment 13 – 15

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Policy Pick-up & Enrollment 1. Branch Executive will visit underwriting office on a weekly basis and collect policies (along with proposal form for new cases). Apart from policies, he will also collect following documents: a. Claim documents b. 64 VB Confirmation c. Reply to queries d. Customer grievance

2. Policies will be handed over to Vipul MedCorp Executive by the underwriting office, after filling the Daily Collection Sheet (Annexure 1). The Sheet will be counter signed by Insurance Co. and Vipul MedCorp Executive. Branch to maintain a policy pick up register underwriting office wise to control documents collections.

3. Vipul MedCorp Executive will do the proposer entry via internet at Vipul MedCorp TAPS Software . Branch to ensure that Proposer entry is done within 24 hrs. (TAT-24 hrs).

4. Batch Creation : After the proposer entry , a batch will be created and all policies along with batch sheet will be filed in one folder.

5. Member Entry: All fields of Insured members like Age , Sex, Sum Insured Exclusions etc will be entered in the TAPS software . Once member entry is complete the branch will proceed with Photo Scanning and authorization of data after quality check.

6. Priting : After the authorization , a batch priting will be done and each cards will be cut to size and will be laminated.

7. The Laminated cards will be put in an envelope along with Guide book and address of Insured along with policy no generated from the system will be pasted on the envelope and would be dispatched.

8. All card packets will be individually couriered and will be entered in outward register

9. The courier POD no. will be entered in TAPS Software to record dispatch details against each individual.

10. In case a dispatched card is returned by courier to Vipul MedCorp, branch due to House Lock, etc., then once again Vipul MedCorp, Branch will re dispatch it after 7 days.

11. In case the re-couriered card is returned after 7 days or address not found or person not available, then the card will be handed over to respective underwriting office with a covering letter. Branch to maintain a register underwriting office wise and take an acknowledgement of cards handed over to U/w office.

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Card Correction 1. All cards received for correction etc. will be entered in the inward register and dispatch will handover the same to enrollment deptt.

2. Enrolllment deptt will do the correction and reprint a new card and dispatch the same to the Insured.

3. Fresh dispatch will be entered in outward register and details of courier POD will be entered in TAPS software.

Enrollment & Business MIS 1. Once a month, Vipul MedCorp, Branch will send a business MIS to all underwriting offices.

2. It will also send a detailed MIS giving card no. issued against each policy no. (with name of insured etc.) to each underwriting office, once a month, giving details of enrollment pertaining to previous month.

Corporate Enrollment 1. Vipul MedCorp, Branch will meet all corporate clients and give a small presentation about its services.

2. Corporate clients will fill corporate policy details (Annexure 2-3-4-5) giving the policy details and their contact details, etc.

3. The details can be taken on a softcopy (e-mail/CD) and photographs will be collected with details (Annexure 5).

4. Vipul MedCorp, Branch will email the soft data details to Vipul MedCorp, Gurgaon who will process the cards and send back the packets to Vipul MedCorp, Branch. Alternatively , Branch can print the cards locally .

5. Vipul MedCorp, Branch will handover the packets to corporate client (HR Manager) with a covering letter and will receive acknowledgement.

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Cashless Process

Fax Intimation 1. Insured who wants to avail of cash less facility have to fill the pre-authorization request form and fax to Vipul MedCorp (Annexure 4). The pre authorization should have following supporting for speedy disposal. a. Policy Copy /Vipul ID Card copy. b. Doctor First prescriptions. c. Pre authorization request form duly completed.

2. Registering Pre authorization Fax – Time of receipt. No of pages received, Legibility of the Fax etc. The data and time will be written on each fax and details will be entered in Incoming Fax register.

Enrollment checking 1. Vipul MedCorp Executive will check if the policy is enrolled. 2. In case the policy is enrolled then VMC Branch will do Cash less

Intimation in the system. 3. In case the policy is not enrolled, then Vipul MedCorp, Branch will collect following documents: a. Policy copy b. 64 VB clearance certificate. In case of a holiday/non-availability of 64 VB confirmation, then Bank Passbook of insured, confirming that premium cheque has been debited in Bank will be collected.

4. Vipul MedCorp, Branch will proceed to do the enrollment. 5. Vipul MedCorp, Branch will do the cashless intimation and process the cashless request. After this stage doctor Assessment will be undertaken and following outcome will be acted upon, a. Query – will be faxed to hospital or to underwriting office . After a querry reply is received then branch will proceed to process the cash less case.

b. Spot Investigation : VMC executive/Doctor will conduct a spot investigation and will discuss the case with treating doctors in case of a doubt .

c. Rejection/Approval – In case of rejection or an approval branch will print the letter from the system and will proceed to fax the same to Hospital.

6. Fax To Hospital: The approval /Rejection letter details will be entered in the outgoing register and the same will be faxed to the hospital.

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Discharge Monitoring / Hospital Coordination 1. Vipul MedCorp, Branch executive will visit the hospital and meet the patient and hospital administrator.

2. Discuss and verify inpatient records and nursing records and coordinate with hospital about discharge formalities.

3. Hospital will prepare the final hospital bills and get the same signed by patient and send following documents to Vipul MedCorp, Branch a. Claim form b. Hospital bills (signed by patient) c. Discharge summary d. All reports e. Vipul MedCorp Authorization letter

4. Vipul MedCorp, Branch will do filling of all claim documents in one folder and will do claim intimation and generate a claim no from the system and thereafter scan the following documents a. Hospital bills b. Discharge summary

These documents will be saved in individual folders of each claimant. 5. Vipul MedCorp, Branch will process the claim and will do detailed Bill

entry and Doctor will assess the case and verify details along with treatment and VMC Authorization letter. All deductions/rejections will be recorded in the system.

6. Query : Any querry generated by doctor will be printed and will be sent to Hospital for their reply. After receiving suitable reply the doctor will authorize the claims

7. After the doctor approval , the complete claim file along with all annexues will be couriered to VMC Gurgaon finance deptt for finanace audit and cheque preparation.

8. VMC HO will receive the claim file and process the cheque and cheques will be either couriered to VMC Branch or the Bank will courier/Handover the cheque to VMC Branch (Single window payments of UIIC)

9. Vipul MedCorp, Branch will hand over cheque to hospital after obtaining a receipt.

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General Intimation

Claim Intimation 1. All claims intimated by fax or phone or e-mail or letter will be recorded at Vipul MedCorp, Branch in General Intimation Register

2. Vipul MedCorp, Branch will also update the records in TAPS Software 3. Claim kit will be sent to insured, requesting him to fill the claim form and submit following documents for processing a. Copy of the Id Card/Policy document. b. Original first prescription of doctor advising hospitalization. c. Claim Form with signature of the claimant. d. Original detailed discharge summary. e. Original hospital bill-consolidated. f. Break up of bills. g. Break up of package. h. Original investigations reports, claims etc. supported with doctor’s prescription

Claim Reimbursement 1. Vipul MedCorp, Branch will receive all claim reimbursement papers either directly from customer or thru DO/BO, Agents, etc.

2. Claim documents will be assorted and filed. Each paper will be serially numbered. (This will ensure that if few papers are removed from the file due to audit etc , then they can be trailed)

3. A claim check list will be filled and if following critical documents are missing then a query letter will be sent to insured a. Claim form b. Hospital bills c. Discharge summary d. Doctor first prescription

4. Vipul MedCorp, Branch will scan the Main Hospital bill and Discharge summary and create a folder at their end.

5. Enrollment checking will be done by Vipul MedCorp, Branch and in case insured is non-enrolled then policy documents and 64 VB certificate will be collected and branch will proceed to do the enrollment.

6. Enrollment of non-network hospital in system: In case the non network hospital is not enrolled in the system , then the branch will collect details of the hospitals like Regn no , bed capacity and after ascertaining that the hospital meets the criteria specified in Mediclaim policy , will proceed to enroll the hospital in TAPS software.

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7. Claim intimation will be done by the Branch and claim no will be generated from the system and the same will be recorded in the file.

8. Bill Entry; Branch will do detailed bill entry of each bill and sub bill in the system.

9. Doctor Assessment : Doctor will do an assessment for clinical eligibility and will also do the deductions of non payable item in the system.

10. Querry/Investigations: In case doctor raises a querry the same will be printed and will be dispatched to the Insured. In case an investigation is required then doctor/Investigator will visit the hospital/Patient and will do a detailed investigation.

11. After suitable querry reply is received/If there is no querry then Doctor will evaluate the file at Branch and will enter the case study at TAPS Software.

12. In case of proposed rejection, the file will be referred to Insurance Company for their opinion. Branch will keep a Xerox of the total file and send the original file along with doctor ,s sheet duly signed by the doctor to the u/w office for their opinion. After receiving confirmation from U/w office branch will proceed to reject the file in the system . Rejection letter will be couriered to Insured after entering details in Dispatch register and after updating courier POD no in TAPS software.

13. In case the doctor approves the case, a case summary will be printed and doctor will sign the same and then will sign on the file and sent the file by courier to Vipul MedCorp, Gurgaon.

14. Vipul MedCorp, HO will do the finance settlement and inform the branch about the settlement by email. Alternatively branch can monitor the case from the system and see the settlement status themselves.

15. Vipul MedCorp, Branch will print a Discharge Voucher (DV) and dispatch to insured.

16. Once Vipul MedCorp, receives a signed DV, it will scan and e-mail the same to Vipul MedCorp, Gurgaon and on the same day claim cheque will be couriered to Vipul MedCorp, Branch

17. Vipul MedCorp, Branch will update in dispatch register and courier the cheque to the Insured.

18. Vipul MedCorp, Gurgaon will e-mail claim float statement to Vipul MedCorp, Branch which will be submitted to RO along with Bank Statement and Bank Book.

19. Replenished claim float cheque received from Insurance Company will be deposited in Branch Claim Float A/c.

20. Claim float cheque details will be e-mailed to Accounts Deptt. for updation in System.

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MIS Vipul MedCorp, Branch Office will send following MIS: 1. Internal

S.No MIS Type Remarks Frequency To be Copied to

1 Business Collection MIS Insurance Co Wise Weekly + Monthly HO Coodinator

2 Hospital Oustandings 30+ days Weekly + Monthly Network Group

3 Critical Claims 15 + days Retail/Corporate Separately

Weekly + Monthly

Retail Claims Group + Corporate Claims Group

4 Branch Expenses Variance Actual V/s Budgeted Variance to be seen Monthly Finance Group

5 Grievances Outstandings Weekly + Monthly Grievances Group

6 Adminsitration & Statutory Compliances Monthly

7 Insurance Co MIS Compliance Monthly

8 Floats and Fees Status Insurance Co Wise Monthly Finance Group + Claims Finance

9 Attendance + Staff Status Monthly HR + Finance Group

10 Critical Issues

2. External – RO /U/W offices

a. Business MIS b. Claims MIS

i. Intimated ii. Settled iii. Outstanding

3. Float Statement along with BRS / Bank Book

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Network Management Network Management Executive is responsible for following activities: 1. Empanelment of hospitals meeting specifications under mediclaim Policy 2. Collection of rate list and signing of MOU. Sending the MOU and rate list to Vipul MedCorp, Gurgaon for systems empanelment

3. Maintaining relationship and liaison with hospital administration, billing executive and accounts deptt. of hospitals

4. Cashless and discharge coordination: a. Visit to patient, initially or every cashless cases and thereafter for all cases above Rs.50,000/- or first cashless case in each hospital

b. Meet patient and handover get well card and enquire about his health

c. Meet treating doctor and verify inpatient records/nursing records. Discuss date of discharge, line of treatment etc. with doctor.

d. Coordinate discharge formalities with patient and billing deptt. e. Update discharge date in TAPS system f. Collect bills from hospital and Porcess the same g. Handover cheques to hospitals and obtain receipt.

MIS to be maintained by Network Executive

Internal 1. Empanelment MIS 2. Hospital bills ageing (available in systems) 3. Bills not received MIS 4. Patients not discharged MIS

External – MIS to hospitals giving details period-wise of following: 1. Total cashless collected 2. Total cashless approved 3. Total cashless rejected 4. Total cashless outstanding 5. Total bills received 6. Total payment made 7. Total outstanding payments

MIS should be sent to all hospitals. This is on quarterly basis and to major hospitals on a monthly basis.

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Grievances & CRCM Cell 1) All grievances received at branch by phone/fax/letter will be recorded in grievances register. Each letter will be filed in a separate folder.

2) The Grievance details will be simultaneously updated in the TAPS software. A unique grievance no will be generated by the system , which will be recorded in the file.

3) Acknowlegement : System will generate an acknowledgement letter giving grievance no , which will be couriered to the Insured.

4) Branch will prodeed to resolve the grievance and update the resolutions in the system.

5) Insured will be sent a letter about the resolved grievances and after resolution the file will be closed at the branch.

Registers to be maintained by VMC Branch 1) Policy/Document pick up register u/w office wise. 2) Incoming Dak 3) Outgoing Dak 4) Returned Card register. 5) Incoming Fax register 6) Outgoing Fax register 7) Cash less intimation register 8) Claims Intimation register 9) Grievances Register

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Service Deliverables and Process Control

S.No Process Deliverable/TAT Controlls/Checks

1 Policy Pick up Weekly 1) Weekly MIS of Pick up to HO

2) Evaluation of non pick up

2 Proposer Entry Within 24 hrs Manual Check every day by Branch Manager

3 Enrollment & Dispatch

7 days Exception analysis from system

4 Card Correction

7 days Branch Card correction register

5 Returned Cards

Weekly handover to u/w office

Branch Control- Returned Card register

6 Cash less Process

6 hrs 1) Branch register 2) Systems Exception

7 Hospital Payments

30 days or as per MOU terms

Exception analysis from system

8 Claims Settlement


9 MIS Internal External

Weekly/Monthly Monthly

HO Control CEO Monthly reports

10 Grievances Redressal


ho control of branches -...

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