Sample Claim Form Part B - Reimbursement - United Healthcare Form Page 2

ADVERTISEMENT

GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)
DATA ELEMENT
DESCRIPTION
FORMAT
SECTION A - DETAILS OF HOSPITAL
Name of hospital in full
a)
Name of Hospital
Enter the name of hospital
b)
Hospital ID
Enter ID number of hospital
As allocated by the TPA
c)
Type of Hospital
Indicate whether In network or non network hospital
Tick the right option
d)
Name of treating doctor
Enter the name of the treating doctor
Name of doctor in full
e)
Qualification
Enter the qualifications of the treating doctor
Abbreviations of educational qualifications
Enter the registration number of the doctor along with the state
f)
Registration No. with State Code
As allocated by the Medical Council of India
code
g)
Phone No.
Enter the phone number of doctor
Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a)
Name of Patient
Enter the name of hospital
Name of hospital in full
b)
IP Registration Number
Enter insurance provider registration number
As allotted by the insurance provider
c)
Gender
Indicate Gender of the patient
Tick Male or Female
Number of years and months
Enter age of the patient
d)
Age
Use dd-mm-yy format
e)
Date of Birth
Enter date of admission
f)
Date of Admission
Enter date of admission
Use dd-mm-yy format
Enter time of admission
Use hh:mm format
g)
Time
h)
Date of Discharge
Enter date of discharge
Use dd-mm-yy format
i)
Time
Enter time of discharge
Use hh:mm format
j)
Type of Admission
Tick the right option
Indicate type of admission of patient
k)
If Maternity
Use dd-mm-yy format
Date of Delivery
Enter Date of Delivery if maternity
Gravida Status
Enter Gravida status if maternity
Use standard format
Tick the right option
1)
Status at time of discharge
Indicate status of patient at time of discharge
m)
Total claimed amount
Indicate the total claimed amount
In rupees (Do not enter paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a)
ICD 10 Code
Enter the ICD 10 Code and description of the primary
Primary Diagnosis
Standard Format and Open text
diagnosis
Enter the ICD 10 Code and description of the additional
Additional Diagnosis
Standard Format and Open text
diagnosis
Co-morbidities
Enter the ICD 10 Code and description of the co-morbidities
Standard Format and Open text
b)
ICD 10 PCS
Standard Format and Open text
Procedure 1
Enter the ICD 10 PCS and description of the first procedure
Procedure 2
Enter the ICD 10 PCS and description of the second procedure
Standard Format and Open text
Procedure 3
Enter the ICD 10 PCS and description of the third procedure
Standard Format and Open text
Details of Procedure
Enter the details of the procedure
Open text
c)
Pre-authorization obtained
Indicate whether pre-authorization obtained
Tick Yes or No
d)
Pre-authorization Number
Enter pre-authorization number
As allotted by TPA
e)
If authorization by network hospital not obtained, give
Enter reason for not obtaining pre-authorization number
Open text
reason
f)
Hospitalization due to injury
Indicate if hospitalization is due to injury
Tick Yes or No
Cause
Tick the right option
Indicate cause of injury
If injury due to substance abuse/alcohol consumption,
Indicate whether test conducted
Tick Yes or No
test conducted to establish this
Medico Legal
Indicate whether injury is medico legal
Tick Yes or No
Reported To Police
Indicate whether police report was filed
Tick Yes or No
FIR No.
Enter first information report number
As issued by police authorities
Open Text
If not reported to police, give reason
Enter reason for not reporting to police
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E- DETAILS IN CASE OF NON NETWORK HOSPITAL
a)
Address
Enter the full postal address
Include Street, City and Pin Code
b)
Phone No.
Enter the phone number of hospital
Include STD code with telephone number
Enter the registration number of the doctor along with the state
c)
Registration No. with State Code
As allocated by the Medical Council of India
code
d)
Hospital PAN
Enter the permanent account number
As allotted by the Income Tax department
e)
Number of Inpatient beds
Enter the number of inpatient beds
Digits
f)
Facilities available in the hospital
Indicate facilities available in the hospital
Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Sample Claim Form Sample Claim Form Business
Sample Claim Form Cms 1450 Sample Claim Form Cms 1450 Medical
2011 Irmaa Medicare Part B Reimbursement Claim Submission Form 2011 Irmaa Medicare Part B Reimbursement Claim Submission Form Legal
Hyalgan Cms-1500 Sample Claim Form Hyalgan Cms-1500 Sample Claim Form Medical
Hyalgan Cms-1450/ub-04 Sample Claim Form Hyalgan Cms-1450/ub-04 Sample Claim Form Business
Hippaa Sample Claim Form Hippaa Sample Claim Form Medical
Claim Information Form - United Healthcare Claim Information Form - United Healthcare Medical
Claim Information Form - United Healthcare Student Resources - 2015 Claim Information Form - United Healthcare Student Resources - 2015 Medical
United Healthcare Routine Vision Claim Form United Healthcare Routine Vision Claim Form Medical
Part B Overpayment Recovery Unit Voluntary Refund Form - 2014 Part B Overpayment Recovery Unit Voluntary Refund Form - 2014 Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2