Network Provider

Q1:
How to extend direct billing facility to WAPMED member for In-Patient services/Day care procedures/CT-MRI facilities/Specified Out patient facilities?

Step1:
For availing direct billing facility at Network provider the member/dependant approaches the Provider with WAPMED ID card.

Step2:
For planned admission, forward the Initial Intimation Letter (IIL) along with a copy of WAPMED ID card to WAPMED, 3 – 4 days prior to the hospitalization/procedure.

Step3:
For emergency admission forward Initial Intimation Letter along with a copy of WAPMED ID card within 24 hours of hospitalization to WAPMED.

Step4:
WAPMED will issue an authorization letter for the covered services within the eligibility limits as per the policy.

Step5:
Network provider extends credit treatment to the Member / dependants for the authorized services.

Step6:
At the time of discharge Member / dependant leaves back all the original documents with the Network Provider after signing on all the claim documents.

Step7:
If any unauthorized treatment for the ailment/disease, which is not covered under the terms and conditions of the policy or forms a part of excess/ Co-payment/deductible, she/he will have to make the payment to the Network Provider directly.

Step8:
Submit all the original claim documents (as mentioned above) to WAPMED office within 7 working days after the member’s discharge from the Network Provider for early reimbursement.

Q2:
Do’s for network hospitals while serving WAPMED Members for In-Patient services/Day care procedures/CT-MRI facilities/Specified Out patient facilities?

DO’S
  • Check the member’s identification (WAPMED ID card / authorization letter) before extending direct billing facility.
  • Intimate WAPMED office regarding the admission of member through the Initial intimation letter (IIL).
  • Intimate WAPMED at least 3 – 4 days prior to admission for all pre elective cases.
  • Intimate WAPMED office within 24 hours of admission for all emergency cases.
  • Fill the IIL completely and duly signed by the treating doctor before sending (faxing/online) to WAPMED office.
  • Mention the plan of treatment, probable duration of stay and estimated amount for the treatment in the IIL.
  • Intimate WAPMED office regarding approval for extension of authorized coverage amount at least 24 hours prior to discharge time.
  • In case timely authorization/letter of guarantee is not received from WAPMED, kindly intimate the same to WAPMED office to obtain the authorization letter.
  • Extend the direct billing facility as per the authorized guidelines by WAPMED in the authorization letter.
  • Collect the over and above the authorized eligible amount directly from the member at the time of discharge.
  • Collect the amount billed for non-medical items, which are not payable under this insurance scheme.
  • Duly signed claim form by the member has to be submitted along with the claim documents.
Q3:
Don’ts for Network Providers while Serving WAPMED Members for In-Patient services/Day care procedures/CT-MRI facilities/Specified Out patient facilities?

DONT’S
  • Do not hide relevant and factual information regarding the past and present medical history of the member.
  • Do not extend direct billing facility to unauthorized members and for unauthorized ailments / procedures on credit basis.
  • Do not hand over the original documents like discharge summary, reports, bills etc to the member at the time of discharge.
  • Do not extend direct billing facility over and above the authorized limits and services.
Q4:
How to extend direct billing facility to WAPMED member for Out-patient facilities?

Step1:
For availing direct billing facility at Network provider the member/dependant approaches the Provider with WAPMED ID card.

Step2:
The network Provider logs on to the WAPMED website with log-in ID and password provided to them and checks the availability of balance Sum Insured/Excess/deductibles before extending the direct billing facility.

Step3:
After that if the Network Provider extends the direct billing facility then, it has to enter the cost of treatment on the wapmed health card screen and block that amount.

Step4:
Once the member has availed the direct billing facility the Provider’s executive would take a print out of the screen from wapmed website mentioning the balance Sum Insured/Excess/deductibles and the amount authorized/utilized for present facility and take members signature on the same.

Step5:
At the time of leaving the network provider premises, Member / dependant leaves back all the original documents with the Network Provider after signing on all the claim documents.

Step6:
If any unauthorized treatment for the ailment/disease, which is not covered under the terms and conditions of the policy or forms a part of excess/ Co-payment/deductible, she/he will have to make the payment to the Network Provider directly.

Step7:
Submit all the original claim documents (as mentioned above) to WAPMED office within 7 working days after the member’s discharge from the Network Provider for early reimbursement.

Q5:
Do’s for Network Providers while serving WAPMED Members for Out-patient facilities?

DO’S
  • Check the member’s identification (WAPMED ID card / pre – authorization letter) before extending direct billing facility.
  • Check the member’s eligibility and balance Sum Insured under Out patient limit before extending direct billing facility. Intimate WAPMED office regarding any confusion on the same before extending the direct billing facility.
  • Always confirm the eligibility of balance Sum Insured from wapmed website after logging through the log in ID and password provided to the Provider.
  • Always keep the log in ID and password confidential.
  • Collect the over and above the authorized eligible amount directly from the member.
  • Collect the amount billed for non-medical items, which are not payable under this insurance scheme.
  • Duly signed claim form and Health Card (printed from the website) by the member has to be submitted along with the claim documents.
Q6:
Don’ts for Network Providers while Serving WAPMED Members for Out-patient facilities?

DONT’S
  • Do not hide relevant and factual information regarding the past and present medical history of the member.
  • Do not extend direct billing facility to unauthorized members and for unauthorized ailments / procedures on credit basis.
  • Do not hand over the original documents like discharge summary, reports, bills etc to the member at the time of discharge.
  • Do not extend direct billing facility over and above the authorized limits and services.
Q7:
What are documents required to lodge claims with WAPMED for reimbursement?

General
  • Copy of Member ID card with the member’s details.
  • Copy of Civil ID card
  • Copy of the policy papers, if any.
In-Patient services/Day care procedures/CT-MRI facilities/Specified Out patient facilities
  • Copy of Initial Intimation letter and WAPMED authorization letter (In-Patient services/Day care procedures/CT-MRI facilities/Specified Out patient facilities)
  • Original detailed discharge summary
  • Original investigation reports
  • Original Hospital Bill-consolidated and with detail breakup with the patients signature on it
  • Incase of surgical packages – detail breakup of the package
  • Pharmacy bills and breakup
Out-patient facilities
  • Copy of health card printed from the website duly signed by the member
  • Original consultation papers
  • Original investigation reports
  • Original Bills-consolidated and with detail breakup with the patients signature on it
  • Pharmacy bills and breakup
Q8:
What are the standard Billing Protocols?

Points to be remembered for credit billing, before forwarding the documents to WAPMED office, we request you to kindly keep the following points in mind
  • Consolidated Bill for the entire amount raised for the member towards his treatment.
  • Itemized bill break up for all the details mentioned in the consolidated bill.
  • Breakup for room rent ( In patient facility)
  • Pharmacy bill Break up
  • OT consumables and disposable break up
  • Package rate break up
  • Surgeon fee / Anesthetist fee / Asst doctor fee
  • Miscellaneous Break up (kindly provide a detailed Miscellaneous break to avoid Disallowances by Insurance Company).
Q9:
What are the different formats used for WAPMED operational related activities?

  • Initial Intimation Letter
  • Authorization letter / Credit Letter
  • Denial Letter
  • Claim forms
  • Checklist
  • Discharge Summary
  • Additional Information Sheet
Protocol for Direct billing facility In-Patient services/Day care procedures/CT-MRI facilities/Specified Out patient facilities
    Member (along with ID card / WAPMED Authorization letter)
    Network Provider
    Member Enrollment and Eligibility Verification, through ID card / policy papers by the Provider
    Initial intimation Report sent to WAPMED office by the Provider
    Confirmation / denial for the admission on credit basis by WAPMED through Authorization/denial letter
    Admission and Inpatient treatment as per the Authorization letter
    Generation of Credit Bills
    Patient signature on the Bill and Claim form (essential for claim settlement)
    Forwarding the bills for reimbursement to WAPMED
Protocol for Direct billing facility Out patient facilities
    Member (along with ID card)
    Network Provider
    Network Provider logs on to WAPMED website through login ID and password
    Checking of Sum Insured/sub limits/ excess/deductibles by the Provider
    Extending direct billing facility on basis of information retrieved from the website
    Blocking and saving the amount utilized by the member for present facility
    Taking a print out of health card and taking members signature on it
    Generation of Credit Bills after collection of excess/deductibles/non payable expenses
    Forwarding the bills for reimbursement to WAPMED