Pre Authorization Letter

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Cashless Authorization Letter

(Part-D)
Claim Number: HH172446394 ( Pleaes quote this number for all further correspondence ) Date: 16/10/2023
Authorization is valid for admission up to 26/10/2023
Hospital Name : EYE-Q VISION PVT. LTD. (MOTIJHEEL) Name of the Insurance Company : National Insurance Company
Name of TPA : Heritage Health Insurance TPA Pvt. Ltd.
Address : 113/57 Next to Allahabad Bank, Opposite Proposer Name : Punjab National Bank
Moti Jheet, Swaroop Nagar , Kanpur ,
Lucknow , Uttar Pradesh Patient's Member ID/TPA/Insurer : HHS1.0701531138
KANPUR; Uttar Pradesh Id of the Patient:
Pin : 208002
Rohini ID : 8900080046658 Relation with Proposer : Mother
Dear Sir / Madam,
This has reference to the pre-authorization request submitted on 13/10/2023 .We hereby authorize cashless facility as per details mentioned below:
Patient Name : MAYA DEVI Age : 54 Years Gender : F

Policy Number : 251100502310000185 Expected Date of Admission : 16/10/2023
Policy Period : 01/10/2023 To 30/09/2024 Expected Date of Discharge : 16/10/2023
Room category : General Bed Estimated length of stay :1
Eligible Room Category : GENERAL WARD
as per T&C of Policy
Contract
Provisional Diagnosis : R/E CATARACT Proposed line of treatment : RIGHT EYE CATARACT
Authorization Details :-
Date & Time Reference Number Amount Status

14/10/2023 - 11:31 HH172446394 32000.00 Approved
Total Authorized amount:- Rs. Thirty-Two Thousand Only( In Words )
Authorization Remarks :
PLEASE PROVIDE “PATIENT LENS IMPLANT IDENTIFICATION CARD” ALONG WITH THE STICKER AND TAX INVOICE.
Hospital Agreed Tariff :-
I. Package Case
II. Non-package Case
i. ROOM RENT/DAY :
ii. ICU RENT/DAY :
iii. NURSING CHARGES/DAY :
iv. CONSULTANT VISIT CHARGES/DAY :
v. SURGEON FEE/OT/ANESTHETIST :
vi. OTHERS (specify) :
Authorization Summary :-
Total Bill Amount :(INR)

Deductions Detail :(INR)
Discount :(INR)
Co-Pay :(INR)
Deductibles :(INR)
Total Authorised Amount :(INR)
Amount to be paid by lnsured :
Total Deduction Details :-
Deducted Admissible
S.no Description Bill Amount Deduction Reason
Amount Amount
Terms and Conditions of Authorization :-
1. Cashless Authorization letter 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 lnsurer 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 I 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 rcnt 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 policyholder 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 empaneled with the hospital), Network Provider may
give treatment after obtaining specific consent of policyholder.
7. Differential Costs borne by policyholder 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 ofoperation performed and Surgeon's Bill and Receipt.
5. Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge
Name of the Product Group Policy (IBA) and UIN No :- Important Policy terms & conditions ( sub-limits/co-pay/deductible etc)
Authorized signatory :
(Insurer/TPA)
Address :
Nicco House, 5th Floor, 2, Hare Street

KOLKATA; West Bengal
Pin: 700001
Phone: (033) 2248 6430; Fax:(033) 2231 0287

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Cashless Authorization Letter

Patient Name : MAYA DEVI Age : 54 Years Gender : F

Date & Time Reference Number Amount Status

Total Bill Amount :(INR)

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

1. Detailed Discharge Summary and all Bills from the hospital

Nicco House, 5th Floor, 2, Hare Street

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