Sample Claim Form Part B - Reimbursement - United Healthcare Form printable pdf download

SAMPLE CLAIM FORM PART B – REIMBURSEMENT

Form to be filled in by the hospital in concern

CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL

The issue of this Form is not to be taken as an admission of liability

Please indude the original preauthorization request form in lieu of PART A

(To be filled in block letters)

DETAILS OF HOSPITAL

a) Name of the hospital:

(If non network fill section E)

b) Hospital ID:

c) Type of Hospital:

Network

Non Network

S U R N A M E

I R S T

N A M E

M I

D D L E

N A M E

d) Name of the treating doctor:

e) Qualification:

f) Registration No. with State Code:

g) Phone No.

DETAILS OF THE PATIENT ADMITTED

U R

A M E

N A M E

L E

M E

a) Name of the Patient:

M M

d) Age: Years

Months

e) Date of birth:

b) IP Registration Number

c) Gender:

Male

Female

M M

D D

M M

D D

M M

g)Time:

i)Time:

f) Date of Admission:

h) Date of Discharge:

D D

M M

j) Type of Admission:

k) If Maternity

ii. Gravida Status:

Emergency

Maternity

i. Date of Delivery:

Planned

Day Care

Discharge to another hospital

l) Status at time of discharge:

m) Total claimed amount:

Discharge to home

Deceased

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

ICD10 Codes

Description

ICD 10 PCS

Description

i. Procedure1:

i. Primary Diagnosis:

ii. Additional Diagnosis:

ii. Procedure2:

iii. Co-morbidities:

iii. Procedure3:

iv. Co-morbidities:

iv. Details of Procedure:

Yes

c) Pre-authorization obtained:

d) Pre-authorization Number:

e)if authorization by network hospital not obtained, give reason:

Road Traffic Accident

f) Hospitalization due to Injury:

Yes

i. If Yes, give cause

Substance abuse / alcohol consumption

Self-inflicted

No (If Yes, attach reports)

Yes

ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:

iii. If Medico legal:

iv. Reported to Police:

Yes

v. FIR no.

vi. If not reported to police give reason:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Investigation reports

Claim Form duly signed

CT/MR/USG/HPE investigation reports

Original Pre-authorization request

Doctor’s reference slip for investigation

Copy of the Pre-authorization approval letter

ECG

Copy of photo ID card of patient verified by hospital

Pharmacy bills

Hospital Discharge summary

MLC report & Police FIR

Operation Theater notes

Original death summary from hospital where applicable

Hospital main bill

Any other, please specify

Hospital break-up bill

(ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address of the hospital:

City:

State:

Pin Code:

b)Phone No.

c) Registration No. with State Code:

d) Hospital PAN:

e) No of Inpatient beds

f) Facilities available in the hospital: i.OT:

Yes

No ii. ICU:

Yes

iii. Others:

DECLARATION BY THE HOSPITAL

(PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or

concealment of any material fact, our right to claim under this claim shall be forfeited.

D D

M M

Date:

Place:

Signature and Seal of the Hospital Authority:

Sample Claim Form Part B - Reimbursement - United Healthcare Form

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