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The main responsibility of the insurance department is to process pre-approvals from the In-network insurance companies, so that the patient\'s can avail cashless treatment for the approved services.

Direct Billing: Cashless treatment given to patient with or without taking the approval form the In-network insurance companies. The charges will be later claimed from the insurance by the claims department.

Cash & Reimbursement: Patient\'s belonging to out of network insurance companies need to pay the cash and later get it reimbursed from the insurance companies with a claim form filled by the doctor.

Pre-Approval: It is a guarantee of payment or a \xe2\x80\x9cgo ahead\xe2\x80\x9d given by the In-network insurance companies to the hospitals for rendering the direct billing (cashless) facility to the patient\'s for the approved services.

Pre-approval is requested from the insurance in the following scenarios:

• If the cash limit (given by the insurance) is exceeded - Refer handbook,
• If the service falls under the list of services which requires pre-approval- Refer handbook,
• All IP and daycare cases.

Query: When the data provided to the insurance is insufficient, they send us in a form of query which needs to be replied by the treating doctor with his/her sign and seal.

Rejections: The insurance will reject services which falls under general exclusions, If the benefits are exhausted and if the services are not medically justified.

Reconsideration: Once the service is rejected by the insurance company, the treating doctor can appeal the decision by writing a justification/reconsideration request.

General Exclusions: Certain services under each insurance company are excluded and the payment related to these services are to be borne by the patient.

Ex: Infertility, Chronic conditions etc.

O need to check the below check list and if anything is incorrect or missing, need to send the approval for revision

NMC Healthcare