Guidelines Regarding TPA Functions & Claim Processing

Issued by: HDFC ERGO General Insurance Co. Ltd.

Audience: Partner TPAs
Ver :3.1
1. General Claims Processing:
• All claims (cashless or reimbursement) can be processed using scanned documents. Hard copies are not
mandatory, except in exceptional cases where originals may be required.
• Radiology films are not mandatory.
• All Reimbursement claims shall be settled to the insured only.
• Corporate buffer claims are processed as per the policy wording and require approval from Corporate HR only.
Insurer consent is also required, except in cases where special remarks are mentioned in the policy schedule. For
example, if the policy schedule specifically states: "The utilization of the corporate buffer is at the discretion of the
insured, and insurer approval will not be required for each case. The TPA will proceed as per the request received
from the insured."

• Reference to NME List:

o Please strictly follow the complete NME (Non-medical expenses) list (List – 1 to List – 4) as per IRDAI or
HDFC ERGO guidelines for all claim processing, except where special remarks are mentioned in the policy
schedule. For example, if the policy schedule specifically states: “All charges levied by hospital including
but not limited to Hospital Registration fees, surcharge, service charges, attendant charges, admission
charges, booking charges, service charges where nursing charge is also charged, non-adjustable hospital
deposit etc., are payable.” Or Assistant Surgeon fee, Duty Medical Officer (DMO) Charges, RMO Charges,
Nursing Charges are payable.” In such cases, those specified expenses should be considered payable,
Irrespective of the standard NME list. (Email circulated already by our Underwriting team)
• Deduction Remarks:
▪ In cases where deduction remarks are unclear, and if any grievance is raised by the claimant, the entire
settled amount will be treated as recoverable. Therefore, it is mandatory to ensure that deduction remarks
are clearly stated, specific, and easily understandable for each individual case.
▪ Please note: Insurers are required to communicate all deductions and remarks clearly during claim
settlement. This promotes transparency and ensures that policyholders fully understand the reasons
behind any claim reductions).
• Denial Remarks:
▪ All claims denied should have detailed reasons for any claim denial also the same to be made available
in the MIS which is shared with HDFCERGO.

2. Insurer Concurrence Requirements:

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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1
• Claims exceeding ₹1,00,000 should receive insurer concurrence prior to approval, for cashless approval
threshold time limit is 30 min and for reimbursement its 24 hr, if any claim exceeds defined time limit will be
treated as approved from insurer. TPA has to share the mail with IC on considering the case .
• Any reimbursement claim denial should be submitted to the insurer in CRC format. (Format attached.)
• Cashless denials can be processed via email concurrence.
• Claims Reopening: In case of closed or denied claims, insurer approval should be obtained with proper
justifications and supporting documents (if any). The approval email from the insurer should be attached to the
TPA portal.
• The claim reopening date shall be considered as the LDR (Last Document Received).

3. Investigation Guidelines: (Please refer to pages no. 6-7 for detailed Investigation Report Criteria):
• Above 10K value Claims:
o Mandatory in-person investigation for any hospitalization claims received from excluded/suspected/de-
empanelled hospitals (circulated list). Telephonic investigation can be used if justified and approved by
the insurance company.
o Claims below ₹10,000 can be investigated via any mode (in-person/telephonic).
• Non-Compliance & Consequences:
o Any Breach of investigation protocols will result in 100% recovery of the approved claim amount from
TPA.
o Strict adherence to the guidelines is essential to ensure claim genuineness and avoid financial
recovery actions
o No investigation required for OPD, Pre-post, health check-up claims, except in case of any suspicious cases
observed by insurer with consent.
o Pre-post: Main hospitalization claim investigation date can be considered as an investigation date for pre-
post hospitalization claim.

4. Timelines (TATs):
• Reimbursement Investigation TAT: Max 15 days.
• Reimbursement Claim TAT: All claims to be settled within 15 days from the document submission.
• Pre-Auth TAT:
o Initial: Within 1 hour
o Discharge: Within 3 hours

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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1
o Penalties will be applicable for any TAT breaches.

5. NSP ID & Intimation Protocols:

• TPA should include HDFC ERGO NSP ID in all claim intimations.
• Updated NSP ID list shared Monthly.
• Use dummy NSP ID (HEGIC-NN-584891) for OPD, health check-ups, or non-hospitalization claims.
• Blank NSP ID not accepted unless it's unavailable in the database.
• Claims to be intimated within 2 working days of occurrence.

6. Cashless Authorization & Hospital Network: (Please refer to pages no. 8-9 for relevant information related to
Cashless “Anywhere” Process)

• Cashless services may be extended to TPA-network and non-network hospitals with prior HDFC ERGO
approval and if the hospital qualifies anywhere cashless criteria (anywhere guideline already shared).
• TPAs should share all relevant hospital documents, including agreements and banking details within 2 days of
hospitalization.
• TPAs will not allow cashless extension under "Anywhere Cashless" guidelines till the insurer (HDFCERGO)
shares the NSP ID. Also, before to extending the cashless under anywhere guidelines, TPA should collect complete
required documents from hospital and share with insurer for NSP ID creation.

7. GST, UTR & Documentation:

• Include GST details if room rent ≥ ₹5,000.

• UTR number should be updated in real time and shared with the claimant.
• For UTR issues, escalate to:
o suryansh.singh@hdfcergo.com
o lakshay.sharma@hdfcergo.com
o dinkar.pandey@hdfcergo.com
In case of any escalation, please write to madhu.m1@hdfcergo.com

8. Reporting Requirements:

• Daily Reports:
o BIMA SATARK (before 12 noon)
o Out Standing Claims

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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1
o COVID-19 updates
o Denial claims in CRC format
o Daily TAT format (please share the daily processed Pre-Auth (Cashless) and Reimbursement claims
TAT in the shared format. This is a daily requirement and must be shared in an automated manner without
fail, 365 days in a year. Kindly ensure that the report is automated and received by 12:00 PM every day,
including Saturdays, Sundays, and national holidays.

• Fortnightly Reports:
o COVID-19 (1st & 16th of each month)
• Monthly Reports:
o Anywhere Cashless (by 2nd of every month)
o Monthly Intimation Dump (by 2nd of every month)
o Performance PPT (by 10th of every month) C-SAT report mentioning the action taken post to any negative
feedback received from the customer
o IIB-15 C (by 15th of every month)
o Monthly report (already shared format) by 7th of every month.
o Cashless v/s Reimbursement report (already shared format) by 7th of every month
o Monthly denial claims (already shared format) by 7th of every month
o Cashless and reimbursement TAT report for performance matrix calculation (already shared format) by
7th of every month
o Include reasons for any delays in TAT with supporting data.
• Quarterly Reports:
o Quarterly Settled, Denial and Closed claims MIS dump to be shared in the specified format (by 7th of
each quarter-end)
o Compliance clearance certificate (to be shared by 7th of each quarter-end)
o All processed claims (settled/denied) data should include details of both hardcopy and softcopy claim
documents submitted (by 7th of each quarter-end) and the format already Shared.
o BCP (Business Continuity Plan) & DR drill reports (by 7th of each quarter-end)
o Information Security, VAPT and access control reports (by 7th of each quarter-end)

9. PII Information Masking:

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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1

• Below PII (Personal Identified Information) should not be visible and download options to any user (i.e., User, CRM
Insurer).
▪ Date of Birth (DOB)
▪ Mobile number
▪ PAN number
▪ Account detail/Payee details
▪ Any email ID
▪ Aadhar number
It should be encrypted or masked (refer the following masking formats for sensitive information):
▪ Aadhaar Number: `XXXX XXXX 6666` (e.g., `9999 9999 6666` → `XXXX XXXX 6666`)
▪ Mobile Number: `Contact Number* XXXXX X8787`
▪ Email ID: `vaiXXXX@XXXX.com
• Archival Process:

o Retention Period: Scanned claim documents should be archived for a minimum of five (5) years.
o Hard copies: All claim documents should be submitted to insurer (HDFC ERGO) on a quarterly basis.
o Soft Copy: All scanned claim documents to be retained by the TPA for the past five (5) years. After
completion of five (5) years, all related documents should be submitted to insurer (HDFC ERGO) via the
SFTP path / HDD.
▪ (Example: If any claim is processed in September 2020, should have its documents submitted
to insurer (HDFC ERGO) by December 2025).
o Hard Copy: All claim documents should be submitted at HDFC ERGO Delhi NCR or Mumbai locations
(e.g., Q1 (Apr – Jun 2025 ) docs should be submitted by the end of OCT 2025).

10. Recovery:

• Penal interest for delays beyond 15 days post-LDR will be recovered from TPA.
• Clawback: In case of any negative feedback from the customer.
• In case of Audit Observation:
o Wrongly processed claims
o Duplicate payments

11. Key Data security as per IRDAI information and Cyber security Guidelines (2003) as below,
• Data Security:
o Focus on protecting the data itself, not justified the system or network
o Applies to customer data, claims data and medical records.
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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1
• PII Masking:
o Personal identifiable information (PII) such as address, contact numbers, email ID, Aadhar Numbers, PAN
numbers Etc must be masked when displayed on screens not meant for full access.
o Masked data must be used in services or testing environments
o Shared with third parties only when required.
• Access Controls:
o Role based access must be enforced
o Multifactor authentication should be implemented and logged
o Login credentials and email distribution lists must not be shared apart from authorised user.
o Password change prompt on first login.

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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1

Investigation Report Criteria

Investigation Report Requirements:

All the claims received from the suspected/de-empanelled/flagged hospitals, to be investigation reports should include
the following mandatory details:

A. Basic Details:

1) Date of Admission & Discharge (DOA & DOD)

a. Time is mandatory in 1-day hospitalization cases (unless it's a day-care case and time is documented
separately in any other documents).
2) Treating Doctor's Name & Qualification
3) Complete Treatment Details
a. Diagnosis
b. Type of Treatment
4) Completed Check-list (including document verification status)
5) Investigator’s Name, Signature, Stamp, Date

B. Investigation Report Format:

The investigation report should clearly cover the following details:

1) Trigger Points for Mandatory Investigation:

a. RTA (Road Traffic Accident) Cases:
i. Should rule out alcoholic history.

b. Slip & Fall Cases:

i. Collect clear information from the patient.
2) Subject of Investigation:
a. Specifically, the hospital in reimbursement cases.

3) Checklist Completion:
a. Based on available and verified documentation.
4) Key Investigation Observations:
a. Major findings supporting the genuineness of the hospitalization.
5)Proof of Investigation:
a. All reviewed documents.
b. Investigator’s Name, Signature, Stamp, Date & Time.
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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1

6) Telephonic Investigation Requirement:

a. Call recordings to be provided in approved telephonic investigations.
7) Physical Investigation Requirement:
a. Investigator should obtain
b. IP record details
c. Snapshots of the IP records
d. Hospital snapshot clearly reflecting the date and time.

Suggestion - As per guidelines, the insured should intimate their claim at least 72 hours prior from the date of admission in
the case of planned hospitalization and within 24 hours in the case of emergency hospitalization. If we receive a claim
intimation indicating that the insured is being admitted to a hospital that is excluded, suspected or De-empanelment, an
investigation should be initiated during the hospitalization period without any deviation.

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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1

Cashless Anywhere Process Criteria

Before initiating a cashless claim under the “Anywhere” guidelines for any hospitalization, the following points
should be checked:
1. Pre-Check Before Initiating Cashless Anywhere:
▪ For any cashless request under the Cashless Anywhere guideline, the following steps should be followed:
• Step 1: Check Panel Status:
▪ Is the hospital listed in HDFC ERGO panel?
▪ Yes → Follow routine cashless process.
▪ No → Proceed to Step 2.
• Step 2: Check Exclusion Lists:
▪ Check the following lists on the HDFC ERGO website:
o Excluded Hospitals List.
o De-empaneled Hospitals List.
▪ If hospital appears in either list:

o Do not proceed with cashless.

▪ If hospital is not listed in either:
o Proceed with Cashless Anywhere processing, as detailed below.
2. Guidelines for Cashless Anywhere Processing:
When initiating cashless at a non-network hospital (not empaneled), the TPA should:
• Assess the cashless request and verify:
o Policy terms and conditions.
o Diagnosis and treatment details.
o Same diligence as with a network hospital.
• Collect the following mandatory documents from the hospital:
o Signed One-Pager MOU
o Hospital Tariff
o Rohini ID
o Hospital Registration Certificate
o Cancelled Cheque
o PAN
o Consent Letter
o Mandatory Basic Hospital Details Format
o Addendum (if applicable)
➢ Send the complete documentation to HDFC ERGO for NSP Code creation.
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 Guidelines Regarding TPA Functions & Claim Processing
Issued by: HDFC ERGO General Insurance Co. Ltd.
Audience: Partner TPAs
Ver :3.1
3. Process Scenarios:

A. Planned Treatment:
▪ TPA collects all required documents before admission.
▪ Submit to HDFC ERGO for NSP Code generation.
▪ TAT for NSP Code Creation: Within 2 working days from receipt of documents.
B. Emergency Treatment
▪ TPA may extend cashless at the time of admission.
▪ Documents to be collected and submitted to HDFC ERGO within 4–5 days from Date of Admission
▪ TAT for NSP Code Creation: Within 2 days after document submission.
▪ Expected total TAT: DOA + 8 to 9 days.

C. Day Care Admissions:

▪ Cashless can be extended by TPA.
▪ Submit necessary documents within 4–5 days of admission.
▪ NSP Code to be created within DOA + 8 to 9 days.

4. Validity of MOU:
• MOU signed under Cashless Anywhere will remain valid for 3 months.
• After this period, if not revalidated, the hospital will be deactivated from the insurer system.

5. Enclosures / Mandatory Documents Checklist:

a. One-Pager MOU / Tariff
b. Hospital ID
c. Cancelled Cheque
d. Consent Letter (Final)
e. Addendum (if applicable)
f. Basic Hospital Details Format
6. Notes:
• No cashless shall be extended to hospitals listed in the exclusion or de-empanelment lists.
• TATs should be strictly adhered to for NSP Code creation to ensure smooth claims processing.

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