CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL

(TO BE FILLED IN BLOCK LETTERS)

The issue of this Form is not to be taken as an admission of liability

Please include the original preauthorization request form in lieu of PART A

DETAILS OF HOSPITAL
a) Name of the hospital:

SECTION A
(If non network
b) Hospital ID: c) Type of Hospital: Network Non Network
fill section E)
d) Name of the treating doctor:

e) Qualification: f) Registration No. with State Code:

g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient:

b) IP Registration Number: c) Gender: Male Female Third Gender

SECTION B
d) Age: Years Months e) Date of birth:

f) Date of Admission: g) Time: h) Date of Discharge:

i) Time: j) Type of Admission: Emergency Planned Day Care Maternity

k) If Maternity i. Date of Delivery: ii. Gravida Status:

l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased

m)Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) I CD 10 PCS Description

i. Primary
i. Procedure 1:
Diagnosis

ii. Additional
ii. Procedure 2:
Diagnosis

iii. Co_morbidities iii. Procedure 3:

SECTION C

iv. Details of
iv. Co_morbidities
Procedure:

c) Pre-authorization obtained: YES NO d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to Injury: YES NO I. If Yes, give cause Self-inflicted Road Traffic Accident

Substance abuse / alcohol consumption

ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: YES NO (If Yes, attach reports)

iii. If Medico legal: YES NO iv. Reported to Police: YES NO v. FIR no

vi. If not reported to police give reason:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST
Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports

SECTION D
Copy of the Pre-authorization approval letter Doctor's reference slip for investigation

Copy of photo ID card of patient verified by hospital ECG

Hospital Discharge summary Pharmacy bills

Operation Theatre notes MLC report & Police FIR

Hospital main bill Original death summary from hospital where

applicable
Hospital break-up bill Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital:

SECTION D
City State:

Pin Code: b) Phone No: d) Hospital PAN:

c) Registration No. with State Code: e) Number of Inpatient beds

f) Facilities available in the hospital: i. OT : YES NO ii. ICU : YES NO

iii. Others :

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

SECTION E
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have
made any false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited.

Date:
Place: Signature and Seal of the Hospital Authority:
 GUIDANCE FOR FILLING CLAIM FORM - PART B
(To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF HOSPITAL

a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network Tick the right option
hospital
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full

e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor As allocated by the Medical Council of India
along with the state code
g) Phone No. Enter the phone number of doctor Include STD code with telephone number

SECTION B - DETAILS OF THE PATIENT ADMITTED

a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male, Female or Third Gender
d) Age Enter age of the patient Number of years and months
e) Date of Birth Enter time of admission Use dd-mm-yy format
f) Date of Admission Enter time of admission Use dd-mm-yy format
g) Time Enter time of admission Use hh:mm format
h) Date of Discharge Enter time of discharge Use dd-mm-yy format
I) Time Enter time of discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
m) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
primary diagnosis
Additional Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
additional diagnosis
Co-morbidities Enter the ICD 10 Code and description of the Standard Format and Open text
co-morbidities
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the Standard Format and Open text
first procedure
Procedure 2 Enter the ICD 10 PCS and description of the Enter the ICD 10 PCS and description of the
second procedure second procedure
 SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
Procedure 3 Enter the ICD 10 PCS and description of the Standard Format and Open text
third procedure
Details of Procedure Enter the details of the procedure Standard Format and Open text
Details of Procedure Indicate whether pre-authorization obtained Tick Yes or No
d) Pre-authorization Number Enter pre-authorization number As allotted by TPA
e) If authorization by network Enter reason for not obtaining pre Open text
hospital not obtained, give reason authorization number
f) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/ Indicate whether test conducted Tick Yes or No
alcohol consumption, test
conducted to establish this

Medico Legal Indicate whether injury is medico legal Tick Yes or No

Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text

SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted

SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. with State Code Enter the registration number of the doctor As allocated by the Medical Council of India
along with the state code
d) Hospital PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE HOSPITAL

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

Niva Bupa Health Insurance Company Limited; Registered office:- C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024
Disclaimer: Insurance is a subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company
Limited) (IRDAI Registration No. 145). ‘Bupa’ and ‘HEARTBEAT’ logo are registered trademarks of their respective owners and are being used by Niva Bupa Health
Insurance Company Limited under license. Customer Helpline: 1860-500-8888. Website: www.nivabupa.com. CIN: U66000DL2008PLC182918. For more details on
terms and conditions, exclusions, risk factors, waiting period & benefits, please read sales brochure carefully before concluding a sale.

Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920