Cashless health insurance allows policyholders/beneficiaries to receive medical treatment without having to pay upfront to the providers for the medical services/treatment. It covers both outpatient department (OPD) and inpatient department (IPD) expenses, providing financial relief to the beneficiaries.

Ref : OPD cashless section for the advantages and challenges in the cashless insurance

Typical/existing workflow for IPD service delivery and cashless insurance claim :

Workflow details :

  1. An individual/beneficiary schedules an appointment or arrives as a walk-in (emergency) at the healthcare provider's facility

  2. The individual/beneficiary provides necessary details including insurance details, which may involve filling out a form or scanning a QR code to share relevant information.

  3. (Optional) The Healthcare Provider initiates a coverage verification process by contacting the Payer to confirm the high-level service coverage, aiming to determine if the expected services are covered under the Individual's insurance plan.

  4. (Optional) The payer responds back with coverage eligibility details of the plan.

  5. The Healthcare Provider confirms the admission for the individual.

  6. The individual proceeds with the check-in, registration, and finalisation of required service(s) based on their needs and preferences.

  7. (Optional) The Healthcare Provider further engages with the payer to verify treatment coverage, seeking preauthorization for the proposed treatment/service plan and involved cost details as required by the insurance policy. Wherever applicable, this step may be repeated multiple times to signal change in treatment/service plan.

  8. The payer responds back with the preauthorization response for each request alongwith the pre-authorized amount for each procedure, product, service, etc.

  9. The healthcare provider provides the necessary services to the Individual, which may include a range of medical procedures, tests, administration of drugs, products, therapy sessions, or any other relevant treatments.

  10. The healthcare provider initiates the claim submission process by forwarding the relevant details and documents to the payer.

  11. The payer performs the on-the-spot adjudication to evaluate the submitted claim

  12. The payer responds to the healthcare provider with either approval (full or partial) or rejection of the claim.

  13. After receiving the claim response from the payer, the healthcare provider communicates the claim details to the individual, informing them about the approved services and any payment obligations that remain.

  14. The beneficiary proceeds with any necessary payments, settling any remaining balance based on the coverage provided by the insurance policy, and subsequently concludes the treatment or service provision setting.

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