In this guide 6 sections
Track every claim as a file with a path: intimation, documents, pre-authorisation or reimbursement submission, query handling, settlement and payment. Each step has an owner, a date and a proof, such as a claim number, a reply email or a scanned acknowledgement stamped by the hospital desk. Chase any step past its date.
Log the claim the day you hear of it
Open a claim file at the first phone call and note the insured, the policy number, the patient, the hospital and the reason for admission. Mark it planned or emergency.
Ask early about the cashless network. That decides the path the claim takes and the papers you need first, so ask before the family reaches the admission desk with a bag and no cards.
Tell the family what happens next in plain words, because anxious relatives phone again and again and a short message with the claim reference saves everyone time.
- Policy number, member ID and health card details
- Patient name, relationship and age
- Hospital, treating doctor and admission date
- Planned or emergency admission
- Claim intimation reference from the insurer
Handle pre-authorisation for cashless admissions
For a cashless stay the hospital sends a pre-authorisation request carrying the diagnosis and a cost estimate, usually on a form signed by the treating doctor. The insurer may approve, query or reject. Know which has happened. Note the time of each reply.
Check status the same day and again before discharge, since a pending query can quietly hold approval for hours while the patient waits in a bed.
Note any room-rent limit. A patient who takes a larger room than the policy allows may face proportionate deductions on the whole bill, not only the room. Tell the family first. Put the room-rent limit in writing.
Collect documents for reimbursement claims
Reimbursement means the family pays first. The insurer sets a submission deadline after discharge, so write that date on the file on day one, before the discharge papers go astray.
Papers often go missing. Keep a checklist and tick an item only when you hold a legible copy, because a promise to send it tomorrow is not a document.
Scan everything on receipt. A phone photo of a bill with a fold across the total will draw a query that costs two weeks, so rescan it.
- Claim form signed by the insured
- Discharge summary and doctor’s prescription
- Itemised hospital bill and payment receipts
- Diagnostic reports, scans and pharmacy bills
- Cancelled cheque or bank details for the payout
Answer queries and track the settlement
Insurers raise queries for unclear handwriting, missing reports or doubts about a pre-existing condition, and each query restarts part of the review clock. Reply in writing, attach exactly what was asked for, and note the date, the sender and the reference on your file so the trail is complete.
Compare settlement with the bill line by line, because every deduction should carry a reason such as non-payable items, a co-payment or a proportionate cut for room rent. Is the reason vague? Ask for the settlement letter.
Record the payment date and amount. Then close the file.
Review open claims every week
Sort open claims by days since last movement, so the oldest silent file tops your call list and the family hears from you before they have to ask twice.
Keep a plain rule. If a claim has not moved for the stated number of days, you phone the insurer’s claims desk and write that number into the checklist.
Next step: take your five oldest open claims today and write the next action and its date beside each one, then phone the first insurer before lunch.
Health claim follow-up sheet
One page holds one block per claim. The header holds policy, patient and hospital. Below it sit rows for intimation, pre-authorisation, document pack, submission, queries, settlement and payment, each with a due date, a done date and a proof reference. A footer logs calls to the insurer.
Open a blank worksheet to printQuestions owners ask
What is the difference between cashless and reimbursement?
In a cashless claim the insurer settles with the hospital directly, subject to approval, so the family pays only non-payable items and any co-payment at discharge. In reimbursement the family pays first. The documents differ most.
When should an agent chase an insurer?
Chase when a step passes its due date, or when a query has been answered and nothing has moved for several working days afterwards. Quote the claim number, the date of your last reply and the specific document you sent, and ask who owns the file and when to expect an answer.
Can the agent file the claim for the client?
That depends on the insurer. Many accept claim papers through the agent. Check each insurer’s process, and keep the insured’s signed consent on file together with a copy of everything you submitted on their behalf.