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KEY TERMS
Related to Health insurance

Let's read on to understand some of the key terms related to the health insurance cover:
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I have been told that in case of cashless hospitalization of my spouse, I need to send Pre authorization request form. What is Pre authorization Request and who do I need to send it to? Pre authorization form is the form that you get at the insurance desk in the hospital or from the website of the TPA. You may alternately ask your Vantage representative for the same. In case of a planned hospitalization, one is advised to send the filled form atleast 2-3 days prior to the hospitalization date from the insurance desk of the hospital. Usually, the form has 2 parts to be filled one by the insured and the other part by the treating doctor. It typically asks for information related to the insured like name, insurance card number, corporate name etc. which needs to be filled by the insured. Other information required in the form includes - reason for hospitalization, expected number of days of stay in the hospital, estimated cost of treatment etc. The person at the insurance desk verifies its completeness and then faxes it to the TPA. If the claim is approved by TPA, it sends the authorization letter with an initial approved amount for the treatment to the insurance desk at the hospital. In case of any discrepancy, the TPA raises query to the hospital for clarification.

l What is an initial approval and interim bill in case of cashless treatment?

In response to a pre-authorization request, TPA sends an initial approval for the treatment in case of pre-approved cases. In most such cases, initial approval amount will be lesser than the final amount and this fact is known to Hospitals. The initial approval is sent so that the Hospital can continue the treatment of the patient. At the time of discharge, the final bill amount is faxed to the TPA by the hospital and the TPA approves the rest of the amount based on the policy terms and condition of the policy. If the hospitals feels that the actual hospitalization cost during the course of treatment of the patient is significantly exceeding the total estimated amount communicated to the TPA by the hospital in the pre-authorization form, the hospital then sends the interim bill to the TPA asking for further approval. However, the final bill with total treatment cost is sent to the TPA at the time of patient's discharge.
l What are day care procedures? How does it differ from outpatient treatment?

Day Care Procedure refers to medical treatment, and/or surgical procedure which is: undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and which would have otherwise required a hospitalization of more than 24 hours This basically requires admission in the hospital and consequent discharge, however, it does not require 24 hours of hospitalization. For example, chemotherapy, cataract surgery etc.

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KEY TERMS
Related to Health insurance

In case of OPD, no hospitalization is required and it usually includes doctor consultation, dressing of wounds, normal bandaging, casting in case of fracture etc.
l The communication document on my health insurance policy says that the waiting period on non-accidental claims in the first

30 days is waived off. What is meant by waiting period? Waiting period is the period of time from the start of a policy period where the insured is not entitled to make any claims for a particular benefit.
l It has been communicated to us that cashless facility is available only in the network hospitals. What are network hospitals?

Hospitals in the network refer to hospitals or health care facilities that are part of a TPA or insurance company network with which it has negotiated a discount. TPA allows cashless facility in such hospitals to the insured because those hospitals provide services at lower cost to the TPAs/ insurance companies with which they have contracts.
l Our HR has sent us a communication stating domiciliary treatment is not covered under the policy. What is domiciliary

treatment? Domiciliary treatment means medical treatment for a period exceeding 3 days, for an illness/disease/injury which in the normal course would require care and treatment at a Hospital but is actually taken while confined at home under any of the following circumstances: The condition of the patient is such that he/she is not in a condition to be removed to a hospital, or The patient takes treatment at home on account of non availability of room in a hospital.
l In a recent case of hospitalization of my spouse, the hospital asked for my spouse's UHID. What is that?

UHID is the Unique Health identification number. The TPA provides each insured member with a unique number to be able to identify the insured and its details like the name of the corporate the insured belongs to, the benefits he/she is entitled for, the coverage amount etc. It is always mentioned in the health insurance card of the insured.

Please feel free to get in touch with your Vantage representative for any clarification or query you may have. We will be happy to assist you as always!