Cashless claim process in a hospital: a step-by-step guide for the TPA desk
From the patient at the admission counter to the money in the hospital account: the eight steps of a cashless claim, and where each one goes wrong.
A cashless claim moves through the same steps at every hospital, whichever insurer or TPA is paying. Knowing the steps by heart, and what each one needs, is the fastest way to cut queries and get paid sooner.
1. Check the policy at admission
Take the health card or policy number, a photo ID of the patient and the proposer, and confirm the hospital is in the insurer's network. A wrong policy number at this stage follows the claim all the way to settlement.
2. Send the pre-authorisation request
Fill the cashless request form with the diagnosis, the planned treatment, the expected length of stay and the estimated cost, signed by the treating doctor. Attach the investigation reports that support the diagnosis. For a planned admission, send it before the patient is admitted. For an emergency, send it as soon as the patient is stable.
3. Get the initial approval
The insurer or TPA approves an amount, asks a query, or denies. Under the IRDAI master circular on health insurance (May 2024), insurers are expected to decide on a cashless request within one hour.
4. Ask for an enhancement when the bill grows
If the stay is longer or the treatment changes, send an enhancement request with the reason, the updated estimate and the new reports. Do this before discharge, not at the billing counter.
5. Build the final file
Discharge summary, final bill with breakup, pharmacy and investigation bills, reports, the approval letters and the signed claim form. Check names, dates and signatures on every page.
6. Get the final approval and discharge
Send the final bill and discharge summary. IRDAI expects the final authorisation within three hours of the hospital's request.
7. Submit the physical or online file
Many payers still want the original file by courier or at their office, even after online approval. Keep the courier receipt.
8. Follow up until payment
Track every claim by age, reply to queries the same day, and match each bank credit to its claim by UTR number.
Where Ekline Claims helps
Ekline Claims reads the scanned file page by page before it leaves the hospital, lists every missing document and mismatch desk by desk, and tracks the claim from pre-auth to payment.
More from the blog
Documents required for a cashless claim: the complete hospital checklist
The documents insurers and TPAs ask for most often, grouped by the desk that owns them, so nothing is missing when the file is sent.
IRDAI's 1-hour cashless and 3-hour discharge rule: what hospitals need to do
The 2024 master circular gives insurers tight time limits. Hospitals only benefit if their own requests are complete the first time.