JAYASHRI HEALTH CARE & RESEARCH CENTRE is a nursing home offering healthcare services and now accepts health insurance through TPA-managed cashless facilities and reimbursement claims. These services ensure patients can access treatment without immediate out-of-pocket expenses (via cashless) or seek repayment after settling bills (via reimbursement), adhering to Odisha-specific and all-India regulations.

Key Definitions

1. TPA (Third Party Administrator): A company licensed by IRDAI to facilitate health insurance claims between policyholders, hospitals, and insurers. TPAs manage cashless treatment approvals and reimbursement claims.

2. Cashless Facility: Patients receive treatment without upfront payment at network hospitals, with the insurer settling bills directly via TPA.

3. Reimbursement Facility: Patients pay upfront and later claim repayment from the insurer through TPA by submitting bills and documents.

Rules and Procedures

1. Odisha State-Specific Guidelines

While Odisha does not have a standalone set of nursing home insurance TPA rules distinct from national regulations, it adheres to the IRDAI (Third Party Administrators - Health Services) Regulations, 2016, supplemented by state-level healthcare policies and empanelment norms. Key points include:

Empanelment with TPAs: JAYASHRI HEALTH CARE & RESEARCH CENTRE must register with TPAs operating in Odisha (e.g., Medi Assist, Vidal Health, Health India TPA, etc.) to offer cashless services. This requires:

Valid registration under the Odisha Clinical Establishments (Control and Regulation) Act, 1991.

Compliance with state health department standards for infrastructure, staff, and equipment.

Signing a Memorandum of Understanding (MoU) with TPAs, outlining payment terms, treatment protocols, and claim processes.

Cashless Process in Odisha:

Patients present their TPA-issued health insurance ID card (or e-card) at the nursing home’s TPA/Insurance desk.

For planned admissions, notify the TPA at least 48-72 hours prior with a pre-authorization request.

For emergencies, notify within 24-48 hours of admission.

The nursing home submits patient details, treatment plan, and estimated costs to the TPA for approval.

Once approved, treatment proceeds without patient payment, and the TPA/insurer settles the bill as per policy terms.

Reimbursement Process in Odisha:

Patients pay upfront and collect all bills, discharge summaries, prescriptions, and diagnostic reports.

Submit these to the TPA or insurer within 30-60 days (varies by policy) for reimbursement.

Odisha-based TPAs often have regional offices (e.g., Bhubaneswar) to assist with claim processing.

Local Compliance:

Adhere to Odisha’s healthcare pricing norms (if any) to avoid claim rejections due to overcharging.

Maintain records as per state health regulations for audits by TPAs or insurers.

2. All-India Rules (IRDAI and General Insurance Council Guidelines)

Nationally, the framework is governed by IRDAI regulations and the “Cashless Everywhere” initiative (introduced in 2024), expanding cashless access beyond network hospitals. Here’s how JAYASHRI HEALTH CARE & RESEARCH CENTRE aligns with these:

Empanelment as a Network Hospital:

To be a network hospital, sign agreements with multiple TPAs and insurers (e.g., Star Health, ICICI Lombard, New India Assurance).

Meet IRDAI’s minimum criteria: registered under the Clinical Establishments Act, 2010, 24-hour services, qualified staff, and adequate facilities.

Cashless Facility (Network Hospitals):

Patients with TPA-linked insurance present their ID/e-card at admission.

The nursing home submits a pre-authorization form to the TPA, including:

Policy number, patient details, diagnosis, and treatment cost estimate.

TPA approves within 4-6 hours (emergency) or 24-48 hours (planned), subject to policy coverage.

Exclusions (e.g., pre-existing diseases with waiting periods, non-medical expenses) are communicated upfront.

Bills are settled directly by the insurer/TPA post-discharge.

Cashless Everywhere (Non-Network Hospitals):

Under the “Cashless Everywhere” system, even if JAYASHRI HEALTH CARE & RESEARCH CENTRE is not empaneled with a patient’s insurer/TPA:

Notify the TPA/insurer 48 hours prior for planned admissions or within 48 hours for emergencies.

Submit KYC documents, treatment details, and an MoU (if required by the TPA).

TPA evaluates the nursing home’s credentials and approves cashless treatment if policy terms are met.

Non-acceptance by the nursing home or policy exclusions may lead to reimbursement instead.

Reimbursement Facility (All-India):

Patients pay upfront and submit:

Duly filled claim form (available from TPA/insurer websites).

Original bills, payment receipts, discharge summary, prescriptions, and diagnostic reports.

Valid ID proof and policy details.

Submission deadline: 30-60 days post-discharge (varies by insurer).

Processing time: Typically 15-21 days after document submission, with payment credited to the patient’s bank account.