Insurance patients bring money later, not at the counter. A clear claim process keeps cash flowing and rejections low.
The cashless flow
- Verify the policy and patient identity at admission.
- Send pre-authorisation with diagnosis and estimate.
- Receive approval with the approved amount.
- Treat and bill; collect patient share and non-payables.
- Prepare the discharge bill and documents.
- Submit the final claim to the TPA or insurer.
- Handle queries; reconcile the payment received.
Key documents
- ID and policy or card details
- Pre-authorisation form and approval
- Discharge summary and investigation reports
- Itemised bill with co-payment and non-payables separated
Why claims get rejected or short-paid
| Cause | Prevention |
|---|---|
| Incomplete documents | Checklist per claim before submission |
| Stay or charges beyond approval | Request enhancement early |
| Non-payables mixed in | Separate non-payable items on the bill |
| Late submission | Ageing report and reminders |
Claim tracking board
| Status | Action |
|---|---|
| Pre-auth sent | Follow up if no reply in the agreed time |
| Approved | Record approved amount and limits |
| Final claim submitted | Note date for ageing |
| Query raised | Respond quickly with documents |
| Paid or short-paid | Reconcile and record the difference |
Reviewing this board weekly with the TPA desk keeps old claims from being forgotten.
Tip: Track claims by status and ageing weekly. Money stuck in queries is usually recoverable if you act early.
Related guides: Hospital Management Software in India (NexoraHMS)
Hospital TPA & Insurance Billing Software IndiaHospital Management Software IndiaHospital Billing Best PracticesCGHS and ECHS Billing for HospitalsAyushman Bharat PM-JAY for Hospitals
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