Step 1
For availing cashless treatment facility at Network provider the member/dependant approaches the Provider with Sri Gokulam TPA ID card.

Step 2
For planned admission, forward the Pre-authorization Letter (PAL) along with a copy of Sri Gokulam TPA ID card to SRI GOKULAM TPA, 3 - 4 days prior to the hospitalization/procedure.

Step 3
For emergency admission forward Pre-authorization Letter along with a copy of SRI GOKULAM TPA ID card within 24 hours of hospitalization to SRI GOKULAM TPA .

Step 4
SRI GOKULAM TPA will issue an authorization letter for the covered services within the eligibility limits as per the policy.

Step 5
Network provider extends cashless treatment to the Member / dependants for the authorized services.

Step 6
At the time of discharge Member / dependant leaves back all the original documents with the Network Provider after signing on all the claim documents.

Step 7
If any unauthorized treatment for the ailment/disease, which is not covered under the terms and conditions of the policy or forms a part of excess/ Co-payment/deductible, she/he will have to make the payment to the Network Provider directly.

Step 8
Submit all the original claim documents (as mentioned above) to SRI GOKULAM TPA office within 7 working days after the member's discharge from the Network Provider for early reimbursement.

"Dos"-

Check the member's identification (SRI GOKULAM TPA ID card / authorization letter) before extending cashless treatment facility.
Intimate SRI GOKULAM TPA office regarding the admission of member through the Pre-Authorization Letter (PAL).

Intimate SRI GOKULAM TPA at least 3 - 4 days prior to admission for all pre elective cases.

Intimate SRI GOKULAM TPA office within 24 hours of admission for all emergency cases.

Fill the PAL completely and duly signed by the treating doctor before sending (faxing/online) to SRI GOKULAM TPA office.

Mention the plan of treatment, probable duration of stay and estimated amount for the treatment in the PAL.

Intimate SRI GOKULAM TPA office regarding approval for extension of authorized coverage amount at least 24 hours prior to discharge time.

In case timely authorization/letter of guarantee is not received from SRI GOKULAM TPA , kindly intimate the same to SRI GOKULAM TPA office to obtain the authorization letter.

Extend the cashless treatment facility as per the authorized guidelines by SRI GOKULAM TPA in the authorization letter.

Collect the over and above the authorized eligible amount directly from the member at the time of discharge.

Collect the amount billed for non-medical items / inadmissible items, which are not payable under this insurance scheme.

Duly signed claim form by the member has to be submitted along with the claim documents.

Do not hide relevant and factual information regarding the past and present medical history of the member.

Do not extend cashless treatment facility to unauthorized members and for unauthorized ailments / procedures

Do not hand over the original documents like discharge summary, reports, bills etc to the member at the time of discharge.

Do not extend cashless treatment facility over and above the authorized limits and services.

General

• Copy of Member ID card with the member's details.
• Copy of the policy papers, if any.
  

In-Patient services/Day care procedures

Copy of Initial Intimation letter and SRI GOKULAM TPA authorization letter (In-Patient services/Day care procedures)

• Original detailed discharge summary
• Original investigation reports
• Original Hospital Bill-consolidated and with detail breakup with the patients signature on it
• Incase of surgical packages - detail breakup of the package
• Pharmacy bills and breakup with prescriptions

Points to be remembered for cashless treatment billing, before forwarding the documents to SRI GOKULAM TPA office, we request you to kindly keep the following points in mind

• Consolidated Bill for the entire amount raised for the member towards his treatment.
• Itemized bill break up for all the details mentioned in the consolidated bill.
• Breakup for room rent ( In patient facility)
• Pharmacy bill Break up with prescriptions
• OT consumables and disposable break up
• Package rate break up
• Surgeon fee / Anesthetist fee / Asst doctor fee

Miscellaneous Break up (kindly provide a detailed Miscellaneous break to avoid Disallowances by Insurance Company).

• Pre-authorization Letter
• Authorization letter
• Denial Letter
• Claim forms
• Checklist
• Discharge Summary
• Additional Information Sheet