TPA Services by Family Health Plan (TPA) Ltd.

Integration of best technology with process

Family Health Plan (TPA) Ltd.

Licensed Third Party Administrat r (TPA) by !"#A ( L. $ % &13) First !S' certi(ied TPA in the c )ntry. !S' 9&&1 % 2&&* +erti(icati n. 1, - years ( e./erience in !ndian Health !ns)rance. 0.cl)sive F c)s n + r/ rate 1r )/s nly. State ( art techn l 2y3 a//licati n 4t

ls. ver 2& milli n lives.

Lar2est TPA ((erin2 nati n 5ide services t

Pan !ndia /resence 5ith 21 ((ices acr ss the c )ntry. TPA 5ith the 5idest net5 r6 h s/ital s/read till district level (33&&-).

'nly TPA t desi2n 4 im/lement Sel( F)nded Schemes ( r 1 vt ( !ndia.

O r Ins rance Partners.

FHPL Foot Prints

+handi2arh

!ew "elhi
7ai/)r L)c6n 5 8h /al !nd re 1)5ahati

FHPLs offices
#ol$ata
8h)bhanesh5ar

Ahmedabad S)rat

& mbai
1 a P)ne

$a2/)r

Hyderabad
:isha6a/atnam %angalore

'hennai
+ chin + imbat re 9ad)rai

Corporate Office Hyderabad Regional Office (4) Mumbai New Delhi Chennai Kolkata Branch Office ( !)

Team FHPL

1121 em/l yees (incl)din2 SF Schemes) Sta(( 5ith s)bstantial e./erience in healthcare services # ct rs3 Para;medical and medical rec rd administrat rs /art ( c re sta(( S)// rted by a dedicated healthcare !T team.

O r !etwor$ (pread
3one $ $ $ $ $ rth rth rth rth rth (tate #elhi Haryana Himachal Pradesh 7ammy 4 6ashmir P)n?ab 4 +handi2arh "a?asthan @ttar Pradesh @ttar6hand !orth Total +hattis2arh 1 a 1)?arat 9adhya Pradesh 9aharashtra 6est Total Assam 8ihar 7har6hand 9ani/)r 9e2halaya 'rissa $a2aland Tri/)ra Best 8en2al 7ast Total Andhra Pradesh Carnata6a Cerala Tamil $ad) P ndicherry (o th Total 8rand total 'o nt of Hospitals 1<1 12, 9 > 11< 1&3 1*< 22 0.+ 13 1& 1,3 ,= =,9 21+ =& 1, 21 1 1 =2 1 3 21< -5, ,31 3=> 13& <39 1& /2*0 -5/* "isco nted Hospitals 11= 9= 1 < <> ,9 1=& 11 5+. 9 = *, 3& 219 -50 12 < > & & 2, & 3 << //+ ==& 19* 31 2>& > +50 /+,* 4 >&.* >,.2 11.1 *,.> ,>.> ,>.2 >,.2 ,& 20.5 <9.2 =& ,,., ,,., =>.> *,.3& =& 33.3 & & ,9., & 1&& 3&., -* *2.* ,> 23.* =2.2 >& *0./ ,,.>

$ rth $ rth $ rth A Best Best Best Best Best A 0ast 0ast 0ast 0ast 0ast 0ast 0ast 0ast 0ast A S )th S )th S )th S )th S )th A A

)epresenting *+, locations Presence in -+. "istricts "isco nt List /012 hospital

FHPL 7nrollment Process and 7 enrollment.

9ember enr lment (additi n / deleti n) services FHPL can /r vide a @"L ( r members t l 2;in and add / delete de/endents Alternatively3 a /eri dical mail can be acted )/ n ( r the additi ns / deleti ns t ta6e e((ect (in line 5ith the a2reement 5ith ins)rer) 'n the a2reed dates3 a re/ rt in e.cel can be 2enerated t be a//r ved by the c r/ rate and sent t the ins)rer directly r thr )2h br 6er. Any re/ rt n a2reed ( rmat can be /r vided t y ) n the additi ns / deleti ns t in/)t int the end rsements ( the ins)rer 'nce )/l aded3 FHPL system 5ill a)t matically sh 5 the /resent rec nciled list ( lives c vered. 'nce a member is live3 his e;card is available (r m the system.

FHPL 'ashless process

START

/+/ 0 less than 12

in for ro#tine cases

Planned Hospitalization Planned and E ergency. E ergency

Process of +#thorization is -ecentralized "ith central electronic onitoring.

+ashle ss D 1 h )r

!e ber approaches the hospital "ith the printo#t of the E$card%FHPL& ' days in advance & get the prea#th for filled Hospital send fax to FHPL. !e ber is inti ated via s s & ail abo#t the receipt of re*#est

!e ber approaches the hospital tell the hospital that he is covered #nder FHPL. Hospital starts the treat ent, relative of e ber to fill the prea#th for and send to FHPL "ithin '( hrs of Hospitalization.

Approved

FHPL receives the fax, check the eligibilty, tariff & coverage. Rejected

Query

!e ber is inti ated via s s & ail abo#t the pendency

)#erry letter sent to the hospital, !e ber gets the re*#ire ent f#lfilled fro the treating doctor.

,ase a#thorized and approval letter sent to the hospital.

-enial letter sent to the hospital."ith the .#stification for denying the cashless to hospital.

+fter getting the *#erry f#lfilled hospital fax the letter to FHPL.

!e ber is inti ated via s s & ail abo#t the approval of re*#est

END

!e ber is inti ated via s s & ail abo#t the denial of re*#est

FHPL 'laims process

START

!e ber s#b its the clai helpdesk

at the

7nco plete -oc# ents 3cr#tiny of the clai for doc# ents
by helpdesk personnel.
,lai ret#rned to the e ber "ith inti ation to the local Hr to get the re*#ired doc# ents and s#b it the clai in the next helpdesk.

,o plete -oc# ents

,o plete doc# ents in ,lai , clai collected by helpdesk personnel for f#rther processing.

Query

,lai s#b ission to FHPL office for processing the clai .

*#ery letter sent to the individ#al e ber by e$ ail "ith a copy to H4. 4e inder 8 3!3 & e$ ail.

Rejected
!ail sent to the e ployee "ith .#stification for denial

Approved

!edical 3cr#tiny, 5illing, +#dit, 9erification, 7nvestigations done to control cost

Pay ent advise to 5ank %6EF/ or ,he*#e&.

4e inder ' 3!3 & e$ ail Final re inder 3!3 & e$ ail sent to e ber "ith a cc to H4.
e ber not able to s#b it the re*#ired doc# ents case is closed.

Member submits t e re!uired docume"ts #t t e e$pdes%& DA' ( )i$$ be cou"ted from t is d#y i" c#se of !ueries&

Pay ent credited to !e bers acco#nt and a a#to ated ail is sent to e ber. 7n case of che*#e the sa e is handed over to e ber.

!ail sent to the e ber, Local H4, ,orporate H4, & 5roker, "ith proper .#stifications for re.ection or closing the clai .

END

TAT9s
'ashless:
Less than <& min ( r r )tine cases 0mer2ency % $

a)th riEati n reF)ired3 re2)lariEati n 5ithin 2= Hrs

)eimb rsement:
+laim !# 2enerati n% Less than 2= Hrs !" 1enerati n/ 9edical scr)tiny% 3 #ays "eady ( r /ayment% ,days Payment% #e/ends

n the ins)rer ran2in2 (r m 3 days t ma.im)m 1& days (r m date ( recei/t ( c m/lete set ( d c)ments/ last set ( d c)ments reF)ired t /r cess the claim.

8rie;ance )edressal TAT9s

!mmediate ac6n 5led2ment

( recei/t ( the 2rievance

TAT ( r 2rievance ;0nr llment / +ard iss)ance; 5ithin 2 B r6in2 #ays TAT ( r 2rievance ; +laims related matter ; 5ithin 3 B r6in2 #ays TAT ( r

ther 2rievances ;Same B r6in2 day.

Help "es$ Acti;ities and 7scalation &atri<

Help des$

Handlin2 all / licy related F)eries + rdinati n ( r Sm th Admissi n

"e2)lar )/date n additi n 4deleti ns ( members and Assist

in case ( 0mer2ency

+ nd)ct 0m/l yee 'rientati n n P licy related iss)es and

+ llecti n ( claim d c)ments.

:eri(icati n ( d c)ments as /er the chec6list F ll 5;)/ ( r de(icient d c)ments Handin2 ver /ayment ( settled claims

7scalation &atri<

Level 1 G L cal call centre /L cal +lient Service 0.ec)tive Level 2 G L cal +lient Servicin2 9ana2er Level 3 G 8ranch 9ana2er/ "e2i nal 9ana2er Level = G 1eneral 9ana2er

7nhance 7mployees &orale

'all 'entre
"edicated member helpline .5=0 !ationwide Toll free /1,,>5.*>5,--

0lectr nically s)// rted systems 9ana2ed by /r (essi nally s6illed man/ 5er +all "ec rdin2 (acility. Assistance in in( rmati n n

$et5 r6 h s/itals 0nr llment stat)s S)// rt services in an 0mer2ency + vera2e eli2ibility +laims; d c)mentati n s)// rt3 F)ery handlin2 1eneral in( rmati n n health /lan.

'laims
? ality of Ad@ dication

A)t mati n ( the claims /r cess in terms (%

+ ;/ay in the / licy3 +a//in2 in the / licy3 S/ecial c nditi ns in the / licy 38lac6 Listed r ca)ti )s H s/itals.
1e 2ra/hic l cati n ( the H s/ital and A)t mati n ( H s/ital Tari((s in System 9atch bet5een nat)re ( disease 4 treatment 2iven !+# and P+S + din2 ( +laims (iles. 9edical scr)tiny 4 9edical a)dit3 S/ecialiEed medical /ini n i( reF)ired. 9)lti level scr)tiny a)dit r and 1&&H c nc)rrent a)dit

Fra d "etection= In;estigations:

Fla2 H s/itals/ +laims + nsec)tive !n(ecti )s 4 Accident +laims H s/ital L cati n di((erent (r m 0m/l yee L cati n 0m/l yee 9)lti/le +laims +riteri n Fertility Treatment3 Hernia 'ver/ricin23 +ataract 'ver/ricin23 etc. "TA cases 5ith s)s/ici n ( Alc h l c ns)m/ti n +laims 5ith tam/ered d c)ments !n;h )se !nvesti2ati n team3 tele veri(icati n team 4 tie;)/ 5ith e.ternal claims investi2atin2 a2encies.

FHPL 'ost &anagement

&illiman 8 ideline9s
First TPA to Implement and integrate &illiman 'odes in cashless and claim processing.

Ad;antages of implementing &illiman 8 ideline9s

@ni( rmity in +laims /r cessin2 + nsistency in admissibility decisi n. +laims ad?)dicati n as /er clinical /r t c l A)t mated len2th

( stay calc)lati n ( d ct rs visit as /er L'S ( c ns)mables 4 medicati n based n

A)t mated calc)lati n A)t mated calc)lati n

clinical /r t c l

6eb 7nabled (er;ices and &I(

FHPL will pro;ide access to its website ( login A password) "ata related to Ins rance plan :

+laims stat)s and @tiliEati n statistics $et5 r6 h s/ital stat)s and 1!PSA $et5 r6 h s/itals. I'I +laims Analysis 'nline +laim !ntimati n I'I +laims Analysis

"etailed &I(
0nr llment Additi n/#eleti ns A)th riEati n Statistics +laims Analysis !+" +laims Stat)s 1rievance "e/ rts 0m/ Feedbac6 analysis.

www.fhpl.ne t

Bal e Added (er;ices.

Hel/ #es6 at +lients l cati n 5herever FHPL has ((ices. #edicated Acc )nt 9ana2er. :!P Ta22in2 4 Pri rity Services Se/arate c)st miEed nline access ( r H" (P licy behavi r 4 Analysis) Health chec6 )/Js can be arran2ed at disc )nted /rices. 1& H disc )nt n the medicines /)rchased (r m A/ ll Pharmacies ( r FHPL

members.

1, H disc )nts n dia2n stics at A/ ll +linics and S"L #ia2n stic +enters3 1& H

#isc )nt at S"L + llecti n centreKs. ,;,& H 'P# #isc )nts at $et5 r6 h s/itals.

9 nthly $e5s letters t clients. "eF)est 8ased S9S services ( r the stat)s ( the claim and 2ettin2 the @H!# n s

( the (amily.

Health Tal6s n vari )s t /ics as reF)ired by the client. Health +am/s li6e3 0ye +am/3 #ental +am/s3 8i metric Health screenin2 (hei2ht3

5ei2ht3 8P3 89!. "and m 8l reF)ired)

d S)2ar3 Physical + ns)ltati n 5ith # ct r3 0+1 i(

FHPL 6ellness Ob@ecti;e

To bring down organiCational health cost.

How to achie;e the abo;e ob@ecti;e: F c)sed +)st miEed #ata based 9eas)rable L n2 term

)eD ired Attit dinal 'hange

Eminent clients

han$ Eo
Absol te

for yo r attentio
FF. FF. Is

O r 'ommitment To (er;e Eo