Employee Health Care Facilities

1. During scrutiny of medical claims forwarded by the campuses/ CUs, it is observed that some claim forms for OPD/IPD reimbursement are not filled properly and documents essentially required to process case with insurance company are either missing or incomplete. Resultantly processing of insurance claims with the insurance company gets delayed (to clear objections).
2. The common mistakes noted in claim form (OPD/IPD) that are source of delays / objections are highlighted for necessary action.
   1. Employer signature and seal (stamp) is missing from the claim form.
   2. Claim form is forwarded to BUHO without the Employee signature.
   3. Employee ID is not inserted (missing).
   4. Incorrect Employee ID is mentioned.
   5. Designation of employee is not mentioned.
   6. Amount for reimbursement is to be written in both ways, i.e. ‘figures’ and words’. Amount in words is often missed out in claim forms.
   7. Claim amount written in ‘figures’ and ‘words’ is not matching with each other.
   8. Claim forms have cutting, using of blanco (whitener fluid), over writing. This is to be avoided. If required than same is to be initialed by the employer.
   9. Section III of IPD form is not filled up properly.
   10. Some claim forms received are still as per the old / nonstandard format and creates problem / difficulty in checking/verifying the detail on the form. Please use correct (OPD/IPD) claim format vide this policy letter.
   11. Documents required with claim (mentioned in the form) are not checked and photocopied receipts/bills are forwarded, without doctor prescription, medicine bill/receipt. Doctor stamp/signature is also missing from the prescription in some cases.
   12. OPD claim limit is not checked by the employee against utilized and claims are therefore returned by insurance company reasoning that the OPD entitlement limit of the employee has expired.
   13. More than one OPD claim form is forwarded for the same person (employee). Claims are to be grouped in one form.
   14. Claims are forwarded to BUHO for treatment of diseases, items that are not covered under the policy. Examples are infertility, cosmetic surgery, baby milk, pampers, mouthwash, etc. List of exclusions (diseases/items) not covered in the health policy is to be checked before forwarding the claim.
   15. IPD claim is forwarded without hospital breakup (itemized) bill, discharge summary, and hospital stamp.
   16. OPD claims using more than one page are to be signed/stamped on all pages by the employee and employer.
   17. Claimed amount is not mentioned properly under column (Self/ family) in OPD claim form. Sub-total is also missing. Amount is to be written in appropriate column and nothing else.
   18. Dates on individual OPD claim form reveal that some forms are held up at respective campus/CU (to forward a sizeable number of forms to Head office). To avoid inconvenience and delays in reimbursement, claims (received from employees during the week) are to be forwarded to head office so as to reach by 1500 hours, Wednesday (weekly basis). Claims (after checking/verification at Head office) to be forwarded to insurance company on Friday.

3.         Documents required for settlement of claims for OPD and IPD (non-panel hospital) are therefore to be checked/ensured by respective campus / CU to process case with Insurance company.