Re-imbursement Procedure (Cashless Procedure)
[TAT- 8 week After submission of all Documents]
Employee submits to claim forms to PMS
PMS checks on all the documemts & submits
Unisons validates the Customer ID
Document Completion Verification
Papers handed to Investigation Team
Claim Papers checked by Insurance trained
Claim checked by Panel of Doctors
Payment released tp PMS
PMS releases the cheque to the Employee
[TAT 24 hours (Mon-Sat)
Employee/ Employees relative needs to inform PMS on the case
Employee approaches network hospital with their Insurance card
Hospital faxes Pre Authorization to TPA
Request recived at TPA Pre Auth Dept
Claims Dept checks for coverage and eligibility
Medical Dept checks for Treatment costs and tariff
Authorization faxed to Hospital
Documents Requirement mandatory for processing of a Claim
Accidental Death Claim
Certified True Copy of the F.I.R lodged by Police Authorities
Post Mortem Report in Original or certified true copy
Certified True Copy of Death Certificate issued by the Municipal Authorities
Local Newspaper clipping if the accident has been reported or Eye Witness’s version of the accident (this is not mandatory but it’s presence reduces the TAT of the Investigating Agency)
Claim form duly filled in, certified
Temporary Total Disablement
Original Certificate from the treating doctor certifying the circumstances & extent of the injury & period of bed rest advised
Original Fitness Certificate from the same doctor mentioning that the claimant is fit to resume duty
Original Certificate from the Employer acknowledging the leave of absence
Documents Requirement mandatory for processing of a Claim (Re-imbursement)
Signed Claim mentioning TPA I.D. No.
Original Discharge Summary must have Date of Admission and Date of Discharge, presenting complaints & their duration, final diagnosis, line of treatment given & advice on discharge.
Time of admission & discharge should be mentioned in Discharge Summary
Original final hospital bill in a proper bill format along with Original Receipt of payment made by the patient to the hospital.
Break up of medicine / pharmacy / drugs / Operation Theatre (OT) drugs charges as mentioned in final bill.
Break up of investigation amount along with original reports for the same.
X-ray films mandatory in fracture/RTA & stone cases.
USG / C.T. Scan / M.R.I films mandatory along with reports
Main Hospitalization Claims
In Road Traffic Accident (RTA) / Fracture cases a certificate from doctor required mentioning circumstances leading to injury / fracture. Was patient under the influence of alcohol / epilepsy / intoxication? – Treating Doctor to issue certification to this effect. Was Medico Legal Certificate (MLC) done? If Yes, certified copy of MLC has to be attached
All the bills must be submitted within 15 days from Date of Discharge from the hospital
Submission of pre-post hospitalization claims
Submit all the relevant bills related to investigation, consultation and any other medical treatment done relating with the ailment for which admission was taken in the hospital
The pre and post hospitalizations bills submitted must relate to period 30 days prior to the main hospitalization and 60 days subsequent to discharge after the MAIN HOSPITALIZATION
Submission of deficiency retrievals
Please attach Xerox of Deficiency letter along with the documents required to clear your file
Note: Xerox Copy of the documents should be kept with the insured at all times for the documents submitted to PHS
You can print an e-card from internet; please follow the following procedure: