7/9/2021 Maharaj Vijayaram Gajapathi Raj College of Engineering(A) Mail - Fwd: Cashless Approved for Patient Name : P Markandeya

rkandeya Raju(S…

HOD (MVGR Civil) <hod.civil@mvgrce.edu.in>

Fwd: Cashless Approved for Patient Name : P Markandeya Raju(Self) Employee

Name :P Markandeya Raju (Emp ID : 44)

1 message

Principal (MVGR) <principal@mvgrce.edu.in> Mon, Apr 26, 2021 at 12:14 PM

To: civil <hod.civil@mvgrce.edu.in>, dean ae <dean.ae@mvgrce.edu.in>, APPALA RAJU KOSURU
<om.mvgr@gmail.com>

---------- Forwarded message ---------

From: <donotreply@fhpl.net>

Date: Mon, Apr 26, 2021 at 12:10 PM

Subject: Cashless Approved for Patient Name : P Markandeya Raju(Self) Employee Name :P Markandeya Raju (Emp
ID : 44)

To: <billinghc_vizag@apollohospitals.com>

Cc: <principal.mvgr@gmail.com>, <om.mvgr@gmail.com>

Cashless Authorization Letter

Date: 4/26/2021 12:00:28 PM

Dear Sir /Madam ,

This has reference to the pre-authorization request submitted on 4/26/2021 7:02:00 AM

Claim Number:21042600001(Please quote this number for all further correspondence)

Authorization is valid for admission up to 5/2/2021 12:00:00 AM or expiry of the policy date whichever is earlier

   
: Apollo Hospitals
Name of Hospital Name of Insurance : National Insurance Co.
Enterprise Ltd
Company Ltd
: Survey No.68P&76,
Address Health City, Chinagadhili, : Family Health Plan
Name of TPA
Arilova Visakhapatnam Insurance TPA Limited
City : Visakhapatnam Proposer Name :
District : VISAKHAPATNAM Patient's Name : P Markandeya Raju
State : Andhra Pradesh Insurer Id of the Patient : 21312308
PinCode : 530040 Relation with Proposer : Self
Rohini ID : 8900080329355

We here by authorize cashless facility as per details mentioned below :

Patient Name : P Markandeya Raju Age(Years) : 41
Policy Number : 560201502010000033 Gender : Male
Expected Date of
Policy Period : 20-05-2020 - 19-05-2021 : 4/25/2021 12:00:00 AM
Admission
Expected Date of
Room category : Single A/C : 5/10/2021 12:00:00 AM
Discharge
Eligible Room Category as Estimated length of stay
: Single A/C : 15
per T&C of Policy Contract (Days)
Provisional Diagnosis : CKD Proposed line of treatment :
: The Principal, M.V.G.R
Corporate Name Branch Code :
College Of Engineering

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7/9/2021 Maharaj Vijayaram Gajapathi Raj College of Engineering(A) Mail - Fwd: Cashless Approved for Patient Name : P Markandeya Raju(S…

Authorization Details:

Date & Time Reference number Amount Status

26/04/2021 -12:00 21042600001-1 20000.00 Approved

Total Authorized amount:- Rs:20000.00(Twenty Thousand )

Authorization Remarks :

Covered for MHD.Validity upto 15 days only..charges related to unrelated investigation and medications not
payable.

Hospital Agreed Tariff:

I. Package case:
i. Agreed Package Rate :
II. Non-package Case:
i. Room Rent/day :
ii. ICU Rent/day :
iii. Nursing Charges/day :
iv. Consultant Visit Charges/day :
v. Surgeon's fee/OT/Anesthetist :
vi. Others (specify) :

Authorization Summary

Total Bill Amount : 67800.00

*Other Deductions : 47800.00
Discount : 0.00
Co-Pay : 0.00
Deductibles : 0.00
Total Authorized Amount : 20000.00
Amount to be paid by insured :

*Other Deduction Details:

S.no Description Bill Amount Deducted Amount Admissible Amount Deduction Reason
1 Others 67800.00 47800.00 20000.00 47800.00/- Not payable ,

Terms and Conditions of Authorization :

1. Cashless Authorization letter is issued on the basis of information provided in Pre- Authorization form.
In case misrepresentation/concealment of the facts, any material difference/ deviation/ discrepancy in
information is observed in discharge summary/
IPD records, then cashless authorization shall stand
null & void. At any point of claim processing, Insurer or TPA reserves right to raise queries for any other
document to ascertain admissibility of claim.
2. KYC (Know your customer) details of proposer/employee/Beneficiary are mandatory for claim payout
above Rs 1 lakh.
3. Network provider shall not collect any additional amount from the individual in excess of Agreed
Package Rates except costs towards non-admissible amounts (including additional charges due to
opting higher room rent than eligibility/choosing separate line
of treatment which is not
envisaged/considered in package).
4. Network provider shall not make any recovery from the deposit amount collected from the Insured
except for costs towards non-admissible amounts (including additional charges due to opting higher
room rent than eligibility/ choosing separate line of treatment
which is not envisaged/considered in
package).
5. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed
Package Rates, the authorized TPA / Insurance Company reserves the right to recover the same or get
the same refunded to the policy holder from the Network
Provider and/or take necessary action as
provided under the MOU.
6. Where a treatment/procedure is to be carried out by a doctor/surgeon of insured's choice (not em
paneled with the hospital),Network Provider may give treatment after obtaining specific consent of
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7/9/2021 Maharaj Vijayaram Gajapathi Raj College of Engineering(A) Mail - Fwd: Cashless Approved for Patient Name : P Markandeya Raju(S…

policy holder.
7. Differential Costs borne by policy holder may be reimbursed by insurers subject to the terms and
conditions of the policy.

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.
3. Diagnostic Test Reports and Receipts supported by note from the attending Medical Practitioner /
Surgeon recommending such Diagnostic supported by note from the attending Medical Practitioner/
Surgeon recommending such diagnostic tests.
4. Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt
5. Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on
discharge

Please send us the above documents / details within 7 days of discharge of the patient in order to
expeditiously reimburse the amount.

Name of the Product : NIC Standard GMP Product and UIN No :

Important Policy terms & conditions (sub-limits/co-pay/deductible etc)

Authorized signatory(Insurer/TPA)

Family Health Plan Insurance TPA Limited

Toll free No : 18004254033

Address: Family Health Plan Insurance TPA Ltd,Srinilaya - Cyber Spazio,Second Floor,Road

No.2,Banjara Hills,Hyderabad-500 034.

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