Review and assess IPD health insurance claims, including cashless pre-authorisation and reimbursement claims.
Examine medical records, discharge summaries, investigation reports, prescriptions, and treatment details.
Evaluate the medical necessity and appropriateness of hospitalization and treatment.
Verify diagnosis, procedures, length of stay, and medical expenses against policy coverage.
Identify discrepancies, missing documents, possible overbilling, and non-payable medical expenses.
Assess claims based on policy terms, exclusions, waiting periods, and applicable guidelines.
Provide medical opinions and recommendations for claim approval, query, or rejection, as per delegated authority.
Coordinate with hospitals, insurance companies, and internal claims processing teams for clarifications and additional documents.
Ensure claims are processed within the prescribed turnaround time (TAT).
Maintain accurate claim assessment records and comply with internal quality standards and regulatory requirements.
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