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WAPMED welcomes you into the fold
of health insurance policyholders. WAPMED, as the preferred
TPA of your insurance company, is glad to provide you
with services in a hassle free manner within the terms
and conditions of your coverage under health insurance
policy. As a Third Party Administrator for your Insurance
Company, WAPMED will provide you the following services:
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ID Card. |
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“Direct Billing Facility”
at all our Network Providers for all eligible ailments/conditions.
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Processing and settlement
of claims under the Health Insurance policy. |
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Call Centre Service. |
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| We request you to check: |
(a) |
Your card for
any discrepancies. If you find any discrepancies, please
bring it to the notice of our office nearest to you or
return the card for rectification. Please keep a xerox
copy of the card before returning it to WAPMED. |
(b) |
Please go through the guidebook
in detail to familiarize yourself with the proper procedures
to be followed while availing the various services offered
by WAPMED. |
(c) |
Please go through your Health
Insurance policy, especially the clauses pertaining to
the exclusions under the policy, in detail to be aware
of, what ailments are covered under the policy and what
ailments/conditions are excluded. |
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| For any doubts or clarifications
and/or information, contact our nearest office or call our office
line or log-on to our website or mail us at info@wapmed.net
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The Health Insurance policy, your
WAPMED card and the guidebook are important documents. Please
keep them in safe custody and carry them with you whenever
you go to a hospital for admission or for availing any medical
facility. |
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| Please quote your UHID number, policy
number and the name of your insurance company in all your correspondence
with WAPMED. |
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| Network Provider and “Direct
Billing Facility”: Network providers are Hospitals,
Nursing Homes, Diagnostic Centres, Clinics who have contracted
with WAPMED to provide direct billing facility, for Inpatient
treatment/Out-patient services/day care services/diagnostic
facilities/consultations, for ailments, diseases and medical
conditions covered under the Health Insurance policy, to all
those who are insured and enrolled with WAPMED. The provisional
list of our Network Providers is attached to the guidebook.
Please note that we are constantly adding to or deleting from
this list and as such to get the most current list of Network
Providers, please contact our nearest office or call us on our
office Number or log on to our website or mail us at info@wapmed.net
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| “Direct Billing Facility”
is the service wherein you need not pay any amounts either as
a deposit at the time of admission or for the hospital bills
at the end of treatment / discharge for the services which are
covered under the policy except for the deductibles/co-payment/excess.
This facility is available only at the Network Providers. To
avail the “Direct Billing Facility” you need to
get an authorization from WAPMED. This authorization along with
a copy of the card issued by WAPMED has to be given to the Network
Provider at the time of admission. |
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| Please Note: WAPMED
will authorize “Direct Billing Facility” at the
Network Providers in all cases eligible under the insurance
policy. “Direct Billing Facility” may be denied
in some of the situations as listed below. |
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In case of any
doubt in the policy terms with respect to the present
ailment. |
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The ailment/condition etc.
not being covered under the policy. |
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The insured amount not being
sufficient to cover the medical expenses. |
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If the request for preauthorization
is not received by WAPMED in time. |
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If the information sent to
WAPMED is insufficient to confirm coverage. |
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| Denial of “Direct Billing
Facility” is not denial of treatment. You can continue
with the treatment, pay for the services to the hospital, and
later send the claim to WAPMED for processing and reimbursement,
which would be processed on merits, based on the policy terms
and conditions. |
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| AVAILING
OF INPATIENT HOSPITALIZATION SERVICES |
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| In case you need to avail inpatient
hospitalization services, you can go to any Medical service
Provider of your choice, either a provider on our network or
a hospital outside the network. The difference between the two
being that WAPMED can authorize for "Direct billing facility"
in the provider on its network whereas you will have to settle
all the bills in the medical service provider which is outside
WAPMED’s network. However you have to follow the procedures
listed below to get the services in different situations. |
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| A)
Emergency hospitalization/consultation/Diagnostic procedure
in Non Network Provider |
Step
1. |
Approach the
nearest hospital/clinic/diagnostic centre. |
Step
2. |
As soon as possible, inform
WAPMED about the hospitalization/medical service used. |
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At the time of discharge/leaving
the provider, settle the bills in full and collect all
the bills, documents and reports. |
| Step 4. |
Lodge your claim with WAPMED
for processing and reimbursement. |
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| B)
Planned hospitalization/consultation/diagnostic procedure
in Non Network Provider |
Step
1. |
Inform WAPMED
about Planned hospitalization/consultation/diagnostic
procedure. |
Step
2. |
Avail the healthcare facility. |
| Step 3. |
At the time of discharge,
settle the bills in full and collect all the bills, documents
and reports. |
| Step 4. |
Lodge your claim with WAPMED
for processing and reimbursement. |
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| C)
Emergency hospitalization/consultation/Diagnostic procedure
in Network Provider |
Step
1. |
Approach the nearest
Network hospital/clinic/diagnostic centre. |
Step
2. |
As soon as possible
inform WAPMED and coordinate with the network provider
to have the details sent to WAPMED for authorization for
direct billing facility. |
| Step 3. |
A) In
case of non-receipt of authorization for "Direct
billing facility" by from WAPMED or if "Direct
billing facility" was denied by WAPMED- |
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(i) |
At the time
of discharge/leaving the network provider premises,
please settle the bills in full and collect all
the bills documents and reports. |
(ii) |
Lodge your claim with
WAPMED for processing and reimbursement |
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B) If
authorization for "Direct billing facility"
from WAPMED has been received |
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(i) |
At the time
of discharge/leaving network provider premises |
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(a) |
Pay for
those items that are not reimbursable under the
Health Insurance policy/excess/co-payments/deductibles. |
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(b) |
Verify the bills and
sign on all the bills. |
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(c) |
Leave the original discharge
summary and other investigations reports with the
network provider. Retain a Xerox copy for your records. |
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| D)
Hospitalization/consultation/Diagnostic procedure at
Network Provider |
Step
1. |
Please
co ordinate with your doctor and the hospital/diagnostic
centre/clinic and send in all the details of your plan
of treatment/diagnostic procedure, cost estimates etc.
to WAPMED. Also indicate the address or fax number to
where the authorization is to be sent. This should be
sent to WAPMED at least 3 days prior to availing the facility,
along with- |
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| (i) |
Photocopy of your ID card. |
(ii) |
Photocopy
of your policy. |
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| FREQUENTLY
ASKED QUESTIONS |
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| Q1. |
What are the services
offered by WAPMED to its beneficiaries? |
| A. |
WAPMED is the service provider
for required Health care service to its members through
activities like - Issuance of ID cards for easy access
at network providers, Direct billing facility at Network
Providers, Member Reimbursement facility for treatment/consultations
at non-network providers, Personalized client servicing,
Enrollment and Claims administration. |
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| Q2. |
How different is WAPMED
from Health Insurance Company? |
| A. |
WAPMED is a Third Party Administrator
(TPA) in health Insurance Sector servicing all insurance
companies. Health Insurance policies for individuals are
basic products of Insurance Companies on which WAPMED
adds value and facilitates smooth operation through its
value-addition like network of healthcare service providers,
medical care standardization, Claims management, Client
servicing, expert opinion etc. Thus WAPMED administers
a `healthcare package' for its clients with customized
healthcare delivery. |
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| Q3. |
Would WAPMED extend
direct billing facility for Out Patient / Out door services
covered under the insurance policy? |
| A. |
Yes. If out patient treatment
coverage forms a part of your insurance cover, WAPMED
would extend direct billing facility to the members at
its Network Providers. |
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| Q4. |
Where can the member
avail the required services? |
| A. |
At all Network Providers if
he / she wants direct billing facility or at any Health
care Service provider where he/she has to pay the amount
first and have to submit the bills along with complete
documents for re-imbursement. |
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| Q5. |
Will location of dependent
family matter in availing services under WAPMED? |
| A. |
No, Location does not affect
the operational activities, main member or the dependant
member can avail same and equal benefits irrespective
of their location. WAPMED’s Network of Healthcare
Service Providers is across the country and worldwide.
These accredited healthcare providers would assure qualitative
healthcare delivery to WAPMED members and WAPMED proactively
monitors and reviews the outcomes of its network. The
worldwide coverage would be provided depending on the
policy that member/group has chosen. |
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| Q6. |
Will the change in
names in between policy period matters? |
| A. |
Yes, According to the Insurance
Company the claim will not be settled (unless prior intimation
to WAPMED and Insurance company) if there is any alterations
in the name and in bills / reports (documents) submitted
by member / Healthcare service provider. |
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| Q7. |
Can I change my or
my dependants name in between the policy period? |
| A. |
Yes, you can change but you
need to intimate WAPMED / Insurance company before hand
with necessary documents (attestation from relevant Government
office). |
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| Q8. |
Should the claim be
submitted with the insurance company or with WAPMED? |
| A. |
Preferably at WAPMED only. |
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| Q9. |
Are there chances
of 'claim rejection'? |
| A. |
WAPMED's network is wide and
is customizable to suit the requirements of the users.
Thus there is little chances of a member utilizing the
services of any other provider out of WAPMED network.
Within the network, if ailment is covered as per the terms
and conditions of the package, the providers will extend
the facilities, on proper verification of the 'Member’s
Manual'. If it is not covered, the member may not be given
the direct billing facility, instead they will be asked
to pay. If the member avails healthcare facilities out
of the network and submits the bills for reimbursement,
the same shall be subject to the terms and conditions
of the healthcare insurance policy. |
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| Q10. |
If I have not utilized
my permissible eligibility amount in a particular policy
period will I get any benefits like carry forward for
the next period if I renew the policy? |
| A. |
The amount will not be carry
forward to subsequent periods. |
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| Q11. |
What are the documents
required to be submitted to WAPMED to claim under reimbursement
procedure? |
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General |
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Copy of Member ID card
with the member’s details. |
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Copy of Civil ID card |
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Copy of the policy papers, if any. |
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In-Patient services/Day
care procedures |
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Original detailed discharge
summary |
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Original investigation reports |
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Original Hospital Bill-consolidated and with detail
breakup with the patients signature |
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Incase of surgical packages – detail breakup
of the package |
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Pharmacy bills and breakup |
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Out-patient facilities |
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Original consultation
papers |
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Original investigation reports |
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Original Bills-consolidated and with detail breakup
with the patients signature on it. |
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Pharmacy bills and breakup. |
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| Note:
Member needs to retain a photocopy of all the documents
he is submitting for future reference. |
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