PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006)
[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]
Plot no.A-442, Road No-28,M.I.D.0 Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code — 400 604
CLAIM ACKNOWLEDGMENT SHEET
Name of Insurer :
PHS ID :
Insured Name :
Employee No :
Patient Name :
Mobile No :
Policy No :
Phone (STD) :
Name of Corporate:
Type of Claim (To
be ticked) :
Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash Benefit
E-Mail ID of
primary insured :
CLAIM DOCUMENT CHECK LIST
Sr. No
Description
Document
Status(Y/N)
Remarks
1
IRDA Claim Form duly signed by the Insured & Hospital
Part-A: Duly signed by the insured with Claimed amount ,Mobile number & Email ID along with PHS ID
Part-B: Duly signed and stamped by hospital
Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals.
1.a
Policy Declaration Form duly signed by the Insured & Hospital hospitals.
2
In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating
reason for the same.
3
Original Cancelled Cheque Leaf of Employee/Proposer with the Name of the AccountHolder Printed on the Cheque
Leaf.
4
ID Proof of Employee / Primary Insured- Any of one (Passport,Voter ID, Driving License, Or any Government
Approved ID ) . If Claim is above 1 lakh- PAN is mandatory with address Proof
5
ID Proof of Patient- Any of one (Passport,Voter ID, Driving License, Or any Government Approved ID )
6
Original detailed Discharge Summary as per IRDA Format / Day care summary from the hospital (in case of Day Care
Treatment) / Death Summary (in Case of Death Claim)
6.a
Copy of the Legal heir certificate (if the claim is for the death of the principle insured)
6.b
Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)
7
Policy Copy ( if individual policy)
8
64VB Compliance Certificate ( If individual policy)
9
Original Final Hospital bill with cost wise breakup of each Item
10
Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)
10.a
Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment
Slip as received from the Vendor
11
Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/ Mesh/ IOL
12
Original bills, original Payment Receipts and investigation / Laboratory Reports
13
Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.
14
Original copy of First Consultation letter and subsequent Prescriptions.
15
Hospital Registration certificate issued by Competent authority as per Indian nursing council Act 1947 (If hospital not
falls
in GIPSA/PPN )
16
OTHER DOCUMENTS
16.a
Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)
16.b
Original Sonography Report in case of Maternity Claim
16.c
Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract
Claim
16.d
Copy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in
case of Road Traffic Accident (RTA)
16.e
A medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along
with the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness
Cases)
16.f
In case of claims where the insured has submitted documents to another insurance cofTPA, he needs to submit
attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills
and receipt for the same in originals.
Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hospital
Claim Submitted by:
Mobile No.
Date of Claim
Submission:
DD /MM/YYYY HH:MM
PHS Executive
Name:
Claim Submitted at:
PHS - (Location) / Help Des!
,
Signature:
Important Points to Remember:-
1. Please mark either V or x against respective check box
2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk
3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital
4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt
of your claim documents by us
5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App
6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved &
agreed
by Insurer
7. Corrections in any documents are not allowed, otherwise it will not be entertained during adjudication.
Kotak Care
Claim Form - Part B
TO BE FILLED BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability
Please include the original preauthorization request form in lieu of PART A
(To be filled in block letters)
DETAILS OF HOSPITAL
a) Name of the hospital :
b) Hospital ID:
d) Name of the treating doctor:
e) Qualification:
c) Type of Hospital Network:
Network
f) Registration No. with State Code:
g) Phone number:
Non Network
(If non network fill section E)
S
U
R N A M E F I R S T N A M E M I D D L E N A M E
DETAILS OF THE PATIENT ADMITTED
a) Name of the Patient:
c) Gender Male Female d) Age Years:
Y Y MM
Months
e) Date of birth:
D D MM Y Y
b) IP Registration Number:
f) Date of Admission:
D D MM Y Y
g) Time:
:
h) Date of Discharge:
D D MM Y Y
I) Time:
:
j) Type of Admission:
k) If Maternity
i. Date of Delivery:
D D MM Y Y
ii. Gravida Status: l) Status at time of discharge:
Discharge to another hospital
m) Total claimed amount:
H H MM
M MH H
Emergency Planned Day Care Maternity
ICU
S
U
R N A M E F I R
S
T N A M E M I D D L E N A M E
Discharge to home
Deceased
DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Codes Description
b) ICD 10 PCS
I. Primary Diagnosis:
ii. Additional Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure:
Description
d) Pre-authorization obtained:
Yes No
e) Pre-authorization Number:
f) if authorization by network hospital not obtained, give reason:
g) Hospitalization due to Injury:
Yes No
I. If Yes, give cause:
ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:
Yes No
(If Yes, attach reports)
iii. If Medico legal:
Yes No
iv. Reported to Police:
Yes No
v) FIR No :
vi. If not reported to police give reason:
Self-inflicted Road Traffic Accident Substance abuse/alcohol consumption
General Insurance
CLAIM DOCUMENTS SUBMITTED - CHECK LIST (Only fill in case of non-network hospital)
Claim Form duly signed
Original Pre-authorization request
Copy of the Pre-authorization approval letter
Copy of photo ID card of patient verified by hospital
Operation Theatre notes
Hospital main bill
Hospital Discharge summary
Hospital break-up bill
Investigation reports
CT/MR/USG/HPE investigation reports
Doctor’s reference slip for investigation
ECG
MLC report & Police FIR
Original death summary from hospital where applicable
Pharmacy bills
Any other, please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (Only fill in case of non-network hospital)
a) Address of the Hospital:
City: State:
Pin Code: Phone No: c) Registration No. with State Code:
d) Hospital PAN: e) Number of Inpatient beds: f) Facilities available in the hospital: I. OT:
Yes No
ii. ICU:
Yes No
iii. Others :
DECLARATION BY THE HOSPITAL (Please read very carefully)
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or
untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited
Date:
D D MM Y Y
Y Y
Place:
Signature and Seal of the Hospital Authority:
GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital
b) Hospital ID
c) T
ype of Hospital
d) Name of treating doctor
e) Qualification
f) Registration No. with State Code
g) Phone No.
Enter the name of hospital
Enter ID number of hospital
Indicate whether In network or non network hospital
Enter the name of the treating doctor
Enter the qualifications of the treating doctor
Enter the registration number of the doctor along
with the state code
Enter the phone number of doctor
Name of hospital in full
As allocated by theTPA
Tick the right option
Name of doctor in full
Abbreviations of educational qualifications
As allocated by the Medical Council of India
Include STD code with telephone number
SECTION B– DETAILS OF THE PATIENT ADMITTED
a) Name of Patient
b) IP Registration Number
c) Gender
d) Age
e) Date of Birth
f) Date of Admission
g) T
ime
Enter the name of hospital
Enter insurance provider registration number
Indicate Gender of the patient
Enter age of the patient
Enter date of admission
Enter date of admission
Enter time of admission
Name of hospital in full
As allotted by the insurance provider
Tick Male or Female
Number of years and months
Use dd-mm-yy format
Use hh:mm format
Enter date of discharge
Enter time of discharge
Indicate type of admission of patient
Use dd-mm-yy format
Use hh:mm format
Tick the right option
h) Date of Discharge
I) Time
j) Type of Admission
Use dd-mm-yy format
k) If Maternity
m) Total claimed amount
Date of Delivery
Gravida Status
l) Status at time of discharge
Indicate the total claimed amount
Enter Gravida status if maternity
Indicate status of patient at time of discharge
Enter Date of Delivery if maternity
In rupees (Do not enter paise values)
Use standard format
Tick the right option
Use dd-mm-yy format
SECTION C– DETAILS OF AILMENT DIAGNOSED (PRIMARY)
Additional Diagnosis
Co-morbidities
a) ICD 10 Code
Primary Diagnosis
Enter the ICD 10 Code and description of the
co-morbidities
Enter the ICD 10 Code and description of the primary
diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
b) ICD 10 PCS
Procedure1
Procedure2
Procedure3
Enter the ICD 10 PCS and description of the first procedure
Enter the ICD 10 PCS and description of the second
Enter the ICD 10 PS and description of the third
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Details of Procedure
Enter the details of the procedure Open text
c) Pre-authorization obtained
d) Pre-authorization Number
e) If authorization by network hospital not
obtained, give reason
Indicate whether pre-authorization obtained
Enter pre-authorization number
Enter reason for not obtain in pre-authorization
number
As allotted by TPA
Open text
Medico Legal
Reported To Police
FIR No.
If not reported to police, give reason
Indicate whether injury is medico legal
Indicate whether police report was filed
Enter first information report number
Enter reason for not reporting to police
As issued by police authorities
Open Text
f) Hospitalization due to injury Indicate if hospitalization is due to injury
Cause
If injury due to substance abuse/alcohol
consumption, test conducted to establish this
Indicate cause of injury
Tick the right option
Indicate whether test conducted
SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECK LIST
SECTION E - ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address
Indicate which supporting documents are submitted
b) Phone No.
c) Registration No. with State Code
d) Hospital PAN
e) Number of Inpatient beds
f) Facilities available in the hospital
Enter the full postal address
Enter the phone number of hospital
Enter the registration number of the doctor along with
the state code
Enter the permanent account number
Enter the number of inpatient beds
Indicate facilities available in the hospital
Include Street, City and Pin Code
Include STD code with Telephone Number
As allocated by the Medical Council of India
As allotted by the Income Tax department
Digits
Tick the right option. If others, please specify
Tick Yes or No
Tick Yes or No
Tick Yes or No
Tick Yes or No
Tick Yes or No
SECTION F - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
Kotak Mahindra General Insurance Company Ltd.
CIN: U66000MH2014PLC260291. Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai – 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg. 21, Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India.
Toll Free: 1800 266 4545 Email: [email protected] Website: www.kotakgeneralinsurance.com IRDAI Reg. No. 152.
POLICY DECLARATION FORM
Date:…………………….
Name of the Hospital :……………………………………………………………………………………………………………………………….
Address:…………………………………………………………………………………………………………………………………………………….
PATIENT NAME (BLOCK LETTERS):…………………………………………………………………… AGE/SEX :……………………….
Mobile No of Patient:…..........................
Date of Admission:………………………………………….. Date of Discharge:……………………………………………
Undertaking by the Patient regarding Heath Insurance Policy
(ा बीमा पॉलिसी के संबंध म रोगी ारा शपथ-प))
I have not declared about any health insurance policy, at the time of Hospital admission.
(
Signature: ………………………………………… ()
Name of the Patient/Patient’s attendant ( )
I have declared about the health insurance policy, at the time of Hospital admission.
( ,
Signature: ………………………………………… ()
Name of the Patient/Patient’s attendant ( )
Undertaking by the Hospital
Based on patient undertaking hospital declare that patient: ( )
Patient did not declare any health insurance coverage, at the time of hospital admission. Hence we will bill
the patient as per our rack rates. We may or may not consider discount for all such undertakings. (
,
)
Patient declared health insurance coverage, at the time of hospital admission. But out of own free will is
opting for reimbursement/ cash paying mode. . As insured is already covered under TPA servicing for which
we are network provider, hence we agree to bill this patient as per PHS or insurer agreed rate list
(whichever is less). The benefit of discount as per MOU will also be given to this patient. (
,
/ .
,
( ) .)
Signature: …………………………………………
Name of the Hospital Representative & Hospital Seal
