Tender Notice Dt - Department of Health , J&K

g) The Insurer needs to file a report to nodal agency explaining reasonsfor denial of every such claim.h) Denial of authorization (DAL)/guarantee of payment is by no meansdenial of treatment by the health facility. The health care providershall deal with such case as per their normal rules and regulations.i) Authorisation letter [AL] will mention the authorization number andthe amount guaranteed as a package rate for such procedure forwhich package has not been fixed earlier. Provider must see thatthese rules are strictly followed.j) The guarantee of payment is given only for the necessary treatmentcost of the ailment covered and mentioned in the request forAuthorisation letter (RAL) for hospitalization.k) The entry on the smart card for blocking as well at discharge wouldrecord the authorization number as well as package amount agreedupon by the hospital and insurer. Since this would not be available inthe package list on the computer, it would be entered manually by thehospital.l) In case the balance sum available is considerably less than thePackage, provider should follow their norms of deposit/running billsetc. However provider shall only charge the balance amount againstthe package from the beneficiary. Insurer upon receipt of the bills anddocuments would release the guaranteed amount.m) Insurer will not be liable for payments in case the informationprovided in the “request for authorization letter” and subsequentdocuments during the course of authorization, is found incorrect ornot disclosed.Note: In the cases where the beneficiary is admitted in a hospital duringthe current policy period but is discharged after the end of the policy period,the claim has to be paid by the insurance company which is operatingduring the period in which beneficiary was admitted.14. Repudiation of claim:In case of any claim is found untenable, the insurer shall communicatereasons in writing to the Designated Authority of the State/ Nodal Agency,Health provider for this purpose with a copy to the beneficiary. Such claimsshall be reviewed by the Central/State/ District Committee on monthly/quarterly basis.15. Delivery of Services by Intermediaries:The Insurer may enter into service agreement(s) with one or more19