Employees Health Scheme EHF Telangana : Claim Process

Organization : Telangana Employees Health Scheme
Facility : Claim Process

Home Page : http://www.ehf.telangana.gov.in/web/guest/ehs
Get More Details here : http://www.ehf.telangana.gov.in/web/guest/claims

Claim Processing :

** All the claims processing shall be carried out electronically through the Trust portal.
** Payments to all the NWHs shall be made through electronic clearance facility of the Trust.

Related : EHF Download Health Card & Edit Employee Details Telangana : www.statusin.in/2992.html

** The claim intimation, collection of claim documents, scrutiny of claim documents shall all be done through the Trust portal.
** The Trust shall follow the claim control number generated by the Trust portal for further reference.

As soon as the claim lands with the Trust, the following verification alone needs to be performed :
** Verification of identity of the patient
** Verification whether the claim amount is limited to pre-authorised amount.
** Verification of case management as per the pre-authorisation.

Verification of evidence of treatment :
** Upon the performance of a listed therapy the NWH initiates a claim. The claim will consist of the identity of patient, pre-authorized listed therapy and pre-authorized amount with enhancement if any, and evidence of performance of listed therapy in the form of an intra-operative photograph or a scar photograph linking the identity of the patient with the therapy or case sheet.
** The Trust upon receipt of the claim shall verify the identity, listed therapy, amount of the claim and evidence
** Upon confirmation by means of a photograph or a medical record such as a case sheet that the listed therapy has been performed, the claim shall be settled and payment made to the NWH within 7 days.
** If the Trust is unable to establish the performance of the listed therapy in the first round of claims scrutiny, the Trust will be allowed to return the claim requesting for specific information from the NWH. Any such request or clarification by the Trust shall not result in additional investigations or diagnostic reports to be performed afresh by the NWH.
** The Trust shall be allowed to send a claim back to NWH for any clarifications only once before final settlement. All remarks relating to the claim ranging from non-medical to medical queries shall be consolidated before being sent back to the NWH.
** An additional time of 7 days will be allowed in case of claim is sent back to the NWH for clarification.
** The Trust issues guidelines from time to time for pre-authorisation and claims settlement which shall be followed scrupulously.

Claim reduction and repudiation :
** Reduction : The settlement of a claim shall be to the full extent of the package price or pre-authorization amount whichever is lower. No disallowance can be made to a claim unless approved by the scheme technical committee of the Trust.
** Repudiation : The Trust may repudiate a claim for reason of not being covered by the policy under intimation to Scheme Technical Committee.