Date:

To

Ref: Empanelment of Your Esteemed Institution for our Third Party Administration Services.

Dear Sir,/Madam:
We are pleased to inform you that your institution is empanelled with MDIndia’s Provider Network to
Provide services to the members of MDIndia Healthcare services Pvt. Limited. Provider code for your
Esteemed institution is ……………………………………………….For any future point of
reference Related to your Institute, please mention the above said code.

Please find enclosed the following formats for future correspondence between MDIndia Healthcare
Services Pvt. Ltd. And you’re esteemed Institute. This will enable efficient coordination, thus
resulting In better services to the policyholders.

1. Guidelines for Cashless Authorization

2 Check-list for Claim Document Submission

3 Request for Cashless Authorization

Please ensure that the formats are circulated to all the concerned departments & executives for smooth
functioning. For any other queries or clarification, please feel free to contact us.

Looking forward for a long – term mutually beneficial relationship.

Regards

Authorized Signatory
Provider Empanelment Department

Enclosed: Copy of Signed MOU with MDIndia Healthcare Services (TPA) Pvt. Ltd.

MDIndia Healthcare Services (TPA) Pvt Limited

IRDA License No. 005

H.O. S.No., -46//1, E-Space, A-2 Bldg., 3rd

Floor Pune Nagar Road, Vadgaon Sheri,
Pune - 411014

UAN Voice : 1860-233-4446

UAN Fax: 1860-233-4447

CUSTOMER CARE NO.: 1800–233-1166

CASHLESS TOLL FREE NO.: 1800-233-4505, CASHLESS FAX NO.: 020 - 25300030
 GUIDELINES FOR CASHLESS HOSPITALIZATION
Modus Operandi for hassle free cashless admission by following simple guidelines:

1. Photo Identification of the patient must be collected for every admission and faxed to MDIndia
either as
MDIndia Photo IDcard
OR
Other Photo Identification proof:

a. Adults: Driving License, Voter ID card, Passport, Election Card, Government Employee
Card, PAN card, photo affixed on policy copy and duly signed by the Insurance company
OR Previous TPA ID Card of the patient
b. Photo ID of School / photo affixed on policy copy and duly signed by the Insurance
company OR Previous TPA ID Card of the patient
2. Policy Copy: It forms an important document of confirmation of member being a covered under
insurance. Hence wherever possible please fax the copy of the policy along with the request for
authorization.
3. Request for Authorization Letter (RAL)(format attached): This needs to be filled in details as
all the information requested for is mandatory and also to avoid additional information requested
for the same. A few examples of necessary information is highlighted below:
a. Investigation results supporting the diagnosis.
b. Line of Treatment supporting the diagnosis
c. Break up of charges for all the estimated expenses
d. Signature/Lt Thumb Impression of the patient or Signature of Guardian
e. Treating Doctor’s Signatures and Seal of the Hospital
f. Insured person contact number
g. In case of Corporate / Group policy: Employee number with date of joining to the
Company should be mentioned
Note: All the information is mandatory that needs to be filled in the RAL.
4. In case, the expenses are likely to increase than the Authorized amount, Additional Request
Form (format attached) can be sent giving the details for expenses and stating the present
condition of the patient.
5. In case the date of admission is prior or after the validity of Authorization letter issued, intimation
regarding the same must be sent to MDIndia so that the needful can be done as the previously
issued authorization would not be considered valid for the changed period of admission.
6. If there is any change in line of treatment e.g. from surgical to conservative or vice a versa. The
same should be intimated at the earliest so as to avoid grievances later regarding the non coverage
of expenses if any.
7. If there is any change in accommodation should be intimated at the earliest so as to avoid
grievances later regarding the non coverage of expenses if any.
8. Non utilization of authorized amount or the additional authorized amount should be informed to
MDIndia prior to discharge of the patient from the hospital so that the necessary documentation
and verification can be done regarding the same.
9. Details about any part payment or co payment or refund details should be given on final hospital
bill.
10. The authorization letter and final hospital bill must be signed by the patient / claimant prior to
discharge from the hospital.
 CHECK LIST FOR CLAIM SUBMISSION

At the time of Request for authorization (to be faxed)

Yes / No

1 Dully filled Request for Authorization form.

2 Patient Photo ID proof.
3 Current year policy copy of insured person

At the time of submission of cashless claim document

Yes / No
1 Authorization letter, Request for authorization letter.
2 Original Hospital bills, Pharmacy bills.
3 Original reports with Laboratory Bills.
4 Original Radiological Investigation reports with Plates.
Original or attested Discharge summary of the hospital with Date
5
and Time of admission & discharge mentioned in it.
6 Claim form signed by the patient or the claimant.
7 Death certificate in death cases.
Attested Photocopy of Indoor case papers if Authorized amount is
8
more Than 1 lakh.
9 Photocopy of Photo Id proof.
Photocopy of Current year policy copy & all previous copy in case of
10
continuation
For the medicines purchased, the bills in original, to be supported by
11 a prescription from the Attending Medical Practitioner/Surgeon
(with Hospital Seal).
Surgeons certificate-stating nature of operations perform and
12
Surgeons Bill and receipt.
Attending Doctors/ Consultants/Specialists /Anesthetists bill receipt
13
and Certificate regarding diagnosis.
FIR or MLC report in accident, if the case has been registered with
14
Local Police station.
15 Invoices for the expensive stents, implants, catheters Etc
16 X-ray Films & all the radiological plates & films
 OUR CONTACT DETAILS

Authorization department: Contact for assistance to utilize the cashless facility

1) Email Id: authorisation@mdindia.com

2) Toll free No: 1800 233 4505.

3) Fax No: 020 - 25300030.

Empanelment department: Contact for any change in provider information,

hospital Tariff or other cases concerned to this

1) Email Id: empanelment@mdindia.com

2) Contact No. 020 – 25300036

Customer Care Department: For Cashless claim Inquiry

1) Toll free No: 1800 233 1166.

2) Call center No: 020 - 25300060-64.