2. TRAINING SESSION
HEALTH INSURANCE CLAIMS ADJUDICATION

3. CONTINUES LEARNING FROM MISTAKES

4. ADAPTING TO PREVAILING MARKET
TRENDS,PRACTICES

5. SELECT THE CORRECT RIDERS AS PER POLICY
 MATERNITY
 HOSPITALIZATION
 OUT-PATIENT
 MAJOR MEDICAL
 CRITICAL ILLNESS
 CORPORATE POOL

6. PRE & POST CLAIMS
PRE & POST SHOULD BE MENTIONED ON FILE

7. BE WELL VERSED WITH THE CLIENT POLICY
 EXCLUSIONS
 PRE EXISTING COVERAGE
 PRE & POST HOSPITALIZATION
 OUT- PATIENT
 WAIVER OF BENCH MARKING IN RE IMBURSEMENT CASES
 PRE & POST NATAL COVERAGE
 POLICY PERIOD

8. PROPERLY STUDY EVALUATE AND REVIEW THE CASE
BEFORE DISCUSSING WITH MANAGER

9. IN SUSPICIOUS CASES MATCH THE TREATMENT
TICKET WITH THE PHARMACY INVOICES

10. PRESCRIBED MEDICATION TERMINOLOGY
 OD ONCE DAILY
 BD TWICE A DAY
 TDS THREE TIMES A DAY
 QID FOUR TIMES A DAY

11. ICU AND ROOM STAY: MATCH THE TOTAL NUMBER
OF DAYS AGAINST THE CHARGED ROOM RENT / ICU
STAY

12. IF A REQUIREMENT RAISED BY EVALUATION DOCTOR
IS NOT FULFILLED DUE TO ANY REASON THEN
WAIVER SHOULD BE AUTHORIZED FROM
CONCERNED DOCTOR / MANAGER

13. IN CASE OF ANY OBJECTION/COMMENT BY
SURVEILLANCE DO NOT PROCEED UNTIL
OBJECTION/COMMENT IS WAIVED OFF

14. BENCH MARKING GUIDELINES
 PANEL HOSPITAL OF SIMILAR STANDARD IN SAME DISTRICT /
ADJACENT DISTRICT
 MENTION THE NAME OF BENCH MARK HOSPITAL ON THE FILE
 TABULATE THE WORKING ON THE PHYSICAL FILE/ EXCEL FOR
FUTURE REFERENCE

15. BASIC BENCH MARKING SCALES
 SURGEON FEE
 ANESTHESIA FEE 1/3 OF SURGEON FEE
 OT FEE 1/3 OF SURGEON FEE
 PHARMACY MEDICINE / LABS
 ROOM RENT