TPA Guidelines

For Emergency and all Health related Services,
Contact ATPAIHPL 24 Hour, Help Line - 1800 425 1111.
Dedicated Help Line: 98450 10136
Phone: # 080 080 41128311. 25364766
E – mail : ravi@anyuta.co, cashless@anyutatpa.com
Web : www.anyuta.co, www.anyutatpa.com

Address:
# Anyuta Corporate Office:
No: 31 / 18 Loyola Layout, Ward – 111, Shanthala Town , Bangalore-560 047.

ANYUTA TPA IN HEALTHCARE PRIVATE LIMITED.

The Anyuta TPA in Healthcare Private Limited (ATPAPL) is a Third Party Administrator in Healthcare (IRDA License No 017) providing Healthcare through its networked Hospitals, Nursing homes, Diagnostic Centers, Clinics, and Doctors and other Healthcare providers across the country to the insured and Non – insured people.

Affordable and Available Health Care

We aim at making, quality Healthcare Affordable and Available to every Indian. Affordability is made possible by Risk pooling, Standardizing the Medical Documentation and Accounting System along with Transparency. The Availability is made possible by integrating the Public and Private Sector Healthcare Delivery System.

Research and development

Our investment in the Research and Development in the field of Healthcare Financing, Delivery System, Documentation and Accounting, resulted in a win – win situation for the Healthcare Financiers, Healthcare Provider Network and the Policyholders.

For the R&D work, we selected one Public Sector Company, The National Insurance Company Limited (NIC), one healthcare Product, Universal Health Insurance Scheme (UHIS), dedicated Network of Hospitals and a group of dedicated doctors, practicing ethical medicine. This resulted in a Health care System, with inbuilt checks and balances, creating a marginal surplus to all the stakeholders and giving the best of healthcare to the Policyholder.

TPA guidelines

a. Health Card

Health Card is to identify you as the beneficiary of the Health Insurance and to give access to our Hospital network willing to provide Cashless Services. Secure your ID card and carry it with you at all times. Quote your Anyuta ID Card No. when you call our Helpline.

Service Providers

APAIHPL Healthcare provider network consists of reputed Doctors, Nurses, Paramedics, Hospitals, Nursing Homes, Daycare Centers, Group practices, Dentists etc., across India.

Use Health Insurance only when needed

Please remember that the Insurance money is nothing but your money. You have paid the premium and the premium will go up based on its usage, hence use it carefully. Do not get admitted to a hospital if it be treated on outpatient basis. Consult with your Family Physician, understand the benefits of Conservative line of Management over the Surgical Intervention, advantage of Home Care over Hospitalized Care and take an Informed Healthcare decision. In case of doubt Anyuta Trust members can call us for help.

Hospitalized care

Once you are admitted in a Hospital, check on every aspect of the Hospitalized care you receive, need for it and the costs. The drugs that you buy and consume should match with the Doctor’s Prescription. Check the rates in the Bill and the expiry date of the Medicine in the package. Always sign on the backside of the Prescriptions, Bills and the Discharge Summery.

Pay your bills and then get reimbursed

We advise you to pay the Bills upfront wherever possible, subsequently submit the Original Claim File. This will help in cutting health care costs for you and the insurer.

Disclaimer

The cashless access in ATPAIHPL network of hospitals is merely a facility extended to you by the TPA under contract with your insurer. The Anyuta TPA does not guarantee the availability, quality and outcome of the treatment. Selection of a network or a non-network hospital is a prerogative of the beneficiary and is responsible for the outcome.

Admission Procedure

The admitting hospital should send Anyuta TPA, a Pre-Authorization request, to avail Cashless Facility. Hence please see that the Hospital sends a Pre-Authorization request to ATPAIHPL, indicating your admission for treatment as soon as possible.

The Physician ordering your admission will have to fill in the following information in the Anyuta Pre-Authorization Form,

  • 1. Diagnosis or the Differential Diagnosis
  • 2. Treatment Plan
  • 3. The approximate duration of stay,
  • 4. The approximate expenses
  • 5. Split Costing
    • a. Ailment and its duration,
    • b. Known past illness if any,
    • c. Hypertension or Diabetes
    • d. The name of the Hospital / Nursing Home and Consultant.
    • e. Contact no. of Consultant / hospital / Policyholder
    • f. The Proposed date of admission.
    • g. Type / Class of accommodation,

Authorization Letter from ATPAIHPL

After due scrutiny of the Pre-Authorization Request, we will promptly respond. Our response is in three forms, Accepted, Accepted with Co – Payment clause, Denied.

Authorization Letter

If accepted, hospital will get an Authorization Letter (AL) along with the Check List for Cashless treatment and guarantee of payment as per the policy guidelines. In case of emergency, hospital should start the treatment without waiting for the TPA formalities.

Expedite your Claim Processing and settlement,

File all the Original Bills, Discharge Summary, Investigation reports etc. as listed in the Check List, pertaining to your treatment. Send this file with a covering letter and the list of enclosed documents to Anyuta TPA. The Cashless service or Reimbursement of the Claim amount is subject to the terms, conditions, exclusions and limitations of your Health Coverage Plan.

Admission Procedure

In case of Planned Admission, register your name with the hospital well in advance.

  • Approach the Admission / Reception Counter of the Hospital on the day of admission with the Authorization Letter and your ID Card. (On request, AMH – TPA IHPL can also arrange to send the Authorization Letter to the Hospital.)
  • The Hospital/Nursing home will admit you and extend the credit facility upto the amount guaranteed by us.

What is Co – Payment?

Charges for the certain facilities are not covered by majority of Health Plan; few of them are as under:

  • Telephone / Fax
  • Food & Beverages for Relatives
  • Barber
  • Ambulance (unless the policy specifically covers it.)
  • External Implants and accessories such as Crutches, spectacles, etc., unless specifically covered.

For the list of non-covered items visit Web : www.anyuta.co

Cost of such services is paid by the patients directly to the Hospital.

CASHLESS FACILITY DENIED

A. In case sufficient information in the prescribed format is not given.

B. In case of ATPAIHPL medical team is not convinced of the eligibility under the coverage, pre-authorization for cashless can be denied.

Since a large percentage of the Hospitalizations are planned, obtain your Authorization Letter in advance.

Pre-existing diseases

Some Insurance Policies, do not cover pre-existing diseases & complications of chronic conditions, you are advised to give all required information to the Medical Team of ATPAIHPL to verify the eligibility well in advance in case of planned surgery.

The denial of Authorization Letter does not mean denial of treatment

Denial does not in any way prevent you from seeking necessary medical attention for hospitalization. In such cases you are advised to file your claim for reimbursement and ATPAIHPL will settle the claim as per eligibility and policy guidelines.

At the time of discharge from Hospital

Request the Hospital to issue a certificate in the name of the insurer, signed by the admitting Doctor stating that

  1. The patient and the relatives were informed about the medical conditions, need for admission, need for investigations, medication, procedures to be conducted and the costs involved.
  2. The admission to treat his injury or illness was absolutely necessary
  3. The investigations conducted, medication given, Invasive or noninvasive procedures done, were all related to the primary diagnosis and were absolutely necessary,
  4. The bills submitted are genuine and are competitive

Submit the original documents file to AMHTPAIHPL for Claim Settlement.

The file should contain the following list of documents with a covering letter,

  • Hospital admitting doctors report as mentioned above
  • Insurance claim form duly signed by the Insured.
  • All Original Doctors and Hospital Bills.
  • Discharge Card / Discharge Summary, specifying the Final Diagnosis.
  • Original Reports of all investigations duly signed by the specialists in charge.
  • Prescriptions and bills of drugs if purchased by you duly signed by the doctor.
  • In case of your payment above Rs.500/- submit the stamped receipts

The Claim Form is available with the Insurer or you can download it from www.anyuta.co Retain a certified copy of all the documents submitted to ATPAIHPL

Please keep the Photocopy of discharge summary and reports.

Medical expenses incurred after discharge from the Hospital will be reimbursed as per your Health Coverage Plan by the insurer. Prescriptions and bills/receipt of such services should be submitted to ATPAIHPL along with Insurance claim form duly signed by you.

Medical expenses incurred at Non Network Hospitals.

Intimate ATPAIHPL by way of E –mail or letter before getting admitted is a must even in a Non - Network Hospital. In case you choose to get treated in a Non – Network Hospital, ask them to sign the MOU with ATPAIHPL and provide Cashless facility to you, or else you will have to pay the cost of your treatment in the first place and ask for reimbursement. To get the best treatment, call us our Doctors they will help you.

Claim settlement

For speedy Claim settlement there should not be any scope for Moral Hazard. Kindly insist on a stamped, preferably numbered Bills and Receipts from the Doctors. Insist on Bills for every service that you have availed in the Hospital including the Doctors Consultation / Procedural Fee. Organize your Receipts and Bills for convenience of accounting and payment.

No: 31/18. Loyola Layout, Main Road, Ward No: 111, Shanthala Town, Bangalore 5600 47
080 41128311 080 25364766
ravi@anyuta.co

anyuta Copyrights © All Rights Reserved