- It is the primary responsibility to ensure timely submission of Pre Auth, Query and obtain an approval from TPA | Insurance in accordance with the defined TAT
- Ensure that all the above data to be captured into Google Sheet
- Assigned Portal
- Maintain guest satisfactions. All telephone calls and email must be responded immediately.
- Ensure proper counselling of the patient by stander about KIMSHEALTH Policy on insured guests
- Maintain regular communication with TPA authorities at all level
DUTIES
- Confirm the patient s TPA is empaneled with our hospital. Please Refer to the Annexure or obtain confirmation from the Marketing Department if in doubt
- Brief normal process of TPA about coverage perks, Co-payment and non medical
- Collect all required documents from the Patient as per the below check list
- Tracker Entry must be maintained properly for more details please refer to the Policy regarding
- Scheme updating in YASASII
- Ensure all Pre Auth documents to be vetted by the IMOs. Deviations must be recorded properly
- Submission of Pre Auth to concerned TPA with the required documents
- Tracking of Pre-Authorization, if approval intimate to patient or denial it must be intimate to IP Billing and Patients
- If the TPA has raised any query and it should be tracked based on the nature of query like clinical and non-clinical. Clinical queries must be handed over to treating doctor as per the defined TAT. Non-Clinical queries must be responded as per the defined TAT
DURING THE TREATMENT
- During the treatment, we have to submit the interim bill with justification on every 07 days for obtaining Enhancement approval and ensure the patient s insurance coverage remain valid and active. If the sum assured exhausted, it should be intimated to the patient and IP billing for collection of difference amount
- If the patient has more than one policy or top up and the patient would like to submit the balance amount to other TPA. It should be intimated to Insurance Operation Head immediately
- Resolve any issues that arises regarding Approval of Pre-Authorization, Query and Discharge process
DISCHARGE PROCESS
- If any queries raised by TPA it should be cleared within defined TAT from the time of query raised
- NMI to be cross verified as per IRDA guidelines and if any deviation must be intimate to concerned TPA via email
- Once cashless is approved, immediately intimate via email with the name of the staff in the signature field to IP billing for further discharge process
- All the claim documents like Pre Auth documentation, Final Approval, if any query raise before approval, Final bill with the standard format to submission team before 10.30 AM on the next working day. Acknowledgement must be recorded in sequence basis
- If any delay in obtaining approval of the claim, based on the concurrence from HOD for further refund processing. The refund amount must be transferred to the Guest and adhere to the refund Policy
- The TPA issued an approval for the treatment but which has not been utilized by the guest then our responsibility to issue non-Utilization certificate to TPA within 5 working days from the date of discharge
OTHERS
- Monthly activity report must be submitted to HOD for evaluation
- Any other prime duties and key tasks assigned by the department head from time to time.
- Implementation of new revenue cycle initiatives and process improvement to enhance efficiency and accuracy
- Update the non-utilization certificate to higher authorities on daily basis
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