Cashless health insurance allows policyholders/beneficiaries to receive medical treatment without having to pay upfront to the providers for the medical services/treatment. It covers both outpatient department (OPD) and inpatient department (IPD) expenses, providing financial relief to the beneficiaries.
Ref : OPD cashless section for the advantages and challenges in the cashless insurance
Typical/existing workflow for IPD service delivery and cashless insurance claim :
Workflow details :
- An individual/beneficiary schedules an appointment or arrives as a walk-in (emergency) at the healthcare provider's facility
- The individual/beneficiary provides necessary details including insurance details, which may involve filling out a form or scanning a QR code to share relevant information.
- (Optional) The Healthcare Provider initiates a coverage verification process by contacting the Payer to confirm the high-level service coverage, aiming to determine if the expected services are covered under the Individual's insurance plan.
- (Optional) The payer responds back with coverage eligibility details of the plan.
- The Healthcare Provider confirms the admission for the individual.
- The individual proceeds with the check-in, registration, and finalisation of required service(s) based on their needs and preferences.
- (Optional) The Healthcare Provider further engages with the payer to verify treatment coverage, seeking preauthorization for the proposed treatment/service plan and involved cost details as required by the insurance policy. Wherever applicable, this step may be repeated multiple times to signal change in treatment/service plan.
- The payer responds back with the preauthorization response for each request alongwith the pre-authorized amount for each procedure, product, service, etc.
- The healthcare provider provides the necessary services to the Individual, which may include a range of medical procedures, tests, administration of drugs, products, therapy sessions, or any other relevant treatments.
- The healthcare provider initiates the claim submission process by forwarding the relevant details and documents to the payer.
- The payer performs the on-the-spot adjudication to evaluate the submitted claim
- The payer responds to the healthcare provider with either approval (full or partial) or rejection of the claim.
- After receiving the claim response from the payer, the healthcare provider communicates the claim details to the individual, informing them about the approved services and any payment obligations that remain.
- The beneficiary proceeds with any necessary payments, settling any remaining balance based on the coverage provided by the insurance policy, and subsequently concludes the treatment or service provision setting.