Vidal Health Insurance TPA Private Limited TPA Services:

Our service professionals deploy innovative technology and best practices to manage the administration of your health insurance policy. We endeavor to become a comprehensive and complete source for health and mediclaim administration and management for the insured as well as the insurer. Our corporate services team have expertise in managing administration during open enrollment and throughout the plan year, notifying employees of their benefits, changes, and ensuring that related systems receive accurate data. Our in house systems team has build a full-service record keeping and administration platform tailored to suit health insurance requirements across all levels of clients. All the above can be offered online through web-based access. At the moment the following services are offered to the clients :

Services:

• Cashless medical service facilitation at network hospital up to the limit authorized by mediclaim/hospitalization Insurance
• Claim processing & reimbursement, for non-network hospitals
• Computerized Medical History records
• Online assistance to Insured during hospitalization & filing of claim documents
• Hospitals/ nursing Homes all over India

Service Level Agreements:

We at Vidal Health Insurance TPA are a group of professionals dedicated to our mission of providing excellent services to our clients (Corporate as well as Retail). For deliverance of services the SLA (Service Level Agreements) are in place, which would be signed with various Insurance companies and the corporate groups. These broadly define the Turn around Time (TAT) for the deliverance of the following services:

1. ID Cards Printing and Dispatch
   • Vidal Health Insurance TPA TAT for the Delivery of cards is within seven (7) days of the receipt of the complete data of insured members and the details of the policy from the insurance company
2. Cashless Authorization / Rejection
   • Cashless authorization requests are to be scrutinized and the decision of acceptance or rejection is to be conveyed to the service provider within 24 hrs. of the receipt of the Pre Hospitalization Authorization Form.
   • In case where a query has been raised the query has to be satisfied by the concerned party and the authorization will be given within 24 hrs. of the receipt of the reply.
3. Claims Settlement / Reimbursement
   • Turnaround Time (TAT) of settlement of reimbursement claims is generally upto 15 days and subject to full documentation compliance.
4. Customer Grievance Redressal
   • TAT for response is max. 2 working days, for any queries or grievance raised by the client.
5. Call Center Responses
   • Vidal Health Insurance TPA operates a 24 * 7 / 365 days Call center to provide instant accessibility to the clients for all information required for medical services facilitation and claims status.
6. MIS Reports
   • Weekly/ Monthly MIS are prepared for the following:
     1. Claims Paid /Outstanding
     2. Premium Collection
     3. ID Cards Processed & Dispatched
     4. Special reports annually for disease wise analysis, total age wise claim incidences etc.
7. Adequate Coverage of Network Hospitals
   • Providing a comprehensive coverage of network hospitals at all locations of client operations.

Vidal Health Insurance TPA has service level agreement for all the above-defined parameters and the same can be incorporated in the client agreement.

Claim Management & Control

Cashless Facilitation Procedure

• Receipt & Record of Data & Member Enrollment (Issuance of Photo ID Card)
• Pre-Admission Authorisation after checking Doctor Prescription, Admission Form,Hospital Information
• Claim form is submitted with Original bills along with Doctor Prescription, Diagnostic Reports & Discharge summary

Claim Reimbursement
When Cash Less Facility is not accorded or Insured goes to a Non Network Hospital then following documents are required :

• Claim Forms
• Original bills with Diagnostic reports
• Doctor’s First prescription
• Discharge summary/certificate

Claims Control

• Original Bills are verified & scrutinised against Standard Discounted Tariff
• Cost Containment by Medical procedure audit & Bill scrutiny
• 2nd Medical opinion taken for complicated cases
• Repricing done on case to case basis.

Cost Containment
Cash Less medical services lead to: :

• Bill Scrutiny before release of payment
• Discounted Rates
• Eliminates Reimbursement Frauds
• Medical Procedure Audit / Elimination of unnecessary prescriptions
• Case Management

All the above leads to Cost Containment and lowering of Claims/Premium Ratio