Approval Officer

at  NMC Healthcare

The main responsibility of the insurance department is to process pre-approvals from the In-network insurance companies, so that the patient’s can avail cashless treatment for the approved services.
Direct Billing: Cashless treatment given to patient with or without taking the approval form the In-network insurance companies. The charges will be later claimed from the insurance by the claims department.
Cash & Reimbursement: Patient’s belonging to out of network insurance companies need to pay the cash and later get it reimbursed from the insurance companies with a claim form filled by the doctor.
Pre-Approval: It is a guarantee of payment or a “go ahead” given by the In-network insurance companies to the hospitals for rendering the direct billing (cashless) facility to the patient’s for the approved services.

Pre-approval is requested from the insurance in the following scenarios:

• If the cash limit (given by the insurance) is exceeded – Refer handbook,

• If the service falls under the list of services which requires pre-approval– Refer handbook ,All IP and daycare cases.

• Query: When the data provided to the insurance is insufficient, they send us in a form of query which needs to be replied by the treating doctor with his/her sign and seal.
  Rejections: The insurance will reject services which falls under general exclusions, If the benefits are exhausted and if the services are not medically justified.
  Reconsideration : Once the service is rejected by the insurance company, the treating doctor can appeal the decision by writing a justification/reconsideration request.
  General Exclusions: Certain services under each insurance company are excluded and the payment related to these services are to be borne by the patient.
  Ex: Infertility, Chronic conditions etc.
  Out-Patient services [OP] : Services without hospitalization
  Day-care/ Day-case: Ambulatory services or procedures with less than or equal to 12 hours of stay.
  In-Patient: Services or procedures requiring more than 12 hours of stay.
  Benefits: Each insurance policy has variable benefits, High-end cards with the maximum benefits and Basic card with less benefits, Benefits are denoted on the cards as OP: Outpatient; IP: In-patient; DN: Dental; MB: Maternity etc.
  Patient responsibility: A part of the total bill is to be shared by the member Known as patzient responsibilty.
  Example: Copay/Deductible: An upfront fixed amount applied on consultation & Coinsurance : % share on the bill.
  DEPARTMENT WORK FLOW: A day in Insurance Department
  The below flow chart explains day to day activities performed by the team member:

Please refer the Job description for details