Cashless Everywhere Facility for Health Insurance – Things to Know

What is Cashless Health Insurance?

It is a type of health insurance policy in which policyholders can avail of healthcare treatment in a network hospital, and the insurer pays the bill for the treatment directly to the hospital. Hence, the policyholder doesn’t have to spend money from the individual’s pocket as the insurance provider settles the bill directly.

What is the New ‘Cashless Everywhere’ Initiative for Health Insurance?

The GIC, along with the health and general insurance companies in India, has started the ‘Cashless Everywhere’ initiative with effect from January 25, 2024. As part of this initiative, cashless treatment under health insurance policies will be extended to all hospitals in the country, whether the hospital is under the health insurance company’s network or not. Hence, individuals covered under a health plan can now avail of a cashless hospitalization facility in any hospital of their choice even if it is not under the network of the insurer.

This makes it convenient for the policyholders to choose a hospital and the doctors of their choice in case of a planned hospitalization. It also helps victims and their family members in case of emergency hospitalization due to an accident.
You may note that so far, health insurance policyholders have been allowed to get cashless hospitalization and treatment facilities only in the network hospitals that the health policy provider/insurer has tied up with. So, if an insured avails of hospitalization and treatment in a non-network hospital, they are likely to pay the bill or the amount at discharge from their pocket and can reimburse the same later from the insurer. However, the introduction of the new initiative of ‘Cashless Everywhere’ will allow policyholders to avail of treatment at any hospital of their choice and get a cashless facility under the best cashless health insurance plan.

How Would the ‘Cashless Everywhere’ Initiative Allow Greater Convenience for Policyholders?

The ‘Cashless Everywhere’ initiative will allow the policyholder to receive treatment in any of their preferred hospitals through a cashless treatment facility. Thus, even if the hospital you are admitted to is not in the network of your insurance company, you can still receive a cashless treatment, and your insurer will settle the bill directly with the hospital.

Hospitals that are registered under the Clinical Establishment Act and have at least 15 beds can now offer cashless hospitalization facilities. This gives policyholders access to over 40,000 hospitals in the country at present for treatment and hospitalization.

What is the ‘Cashless Everywhere’ Initiative Subjected to?

Under the ‘Cashless Everywhere’ initiative, customers are required to be careful about informing the insurance company 48 hours before getting a planned hospital admission and within 48 hours of emergency hospitalization.

However, besides the claims option, other processes of availing health insurance, including premium estimation, remain the same. Hence, no changes in the premium price are expected. The policyholders need to raise the claim under the insurance policy as per the terms and conditions mentioned in the policy document.

How to get Cashless Treatment at Non-Network Hospitals?

Under the ‘Cashless Everywhere’ initiative, policyholders can avail of treatment at non-network hospitals as per the rules/guidelines set by the GIC. The GIC has mentioned three rules to be followed by the health insurance policyholders:

1) Inform the insurer at least 48 hours before the admission (for planned treatment)

2) Inform the insurer within 48 hours of admission (for emergency treatment)

3) The claim would be acceptable in accordance with the terms and conditions of the policy, while the cashless treatment would be allowed in accordance with the operating guidelines of the insurer

Benefits of the ‘Cashless Everywhere’ Initiative

The ‘Cashless Everywhere’ initiative has several benefits. Some of them are included below:

• It will make the claim policy simple and convenient for the policyholders and will save paperwork and time
• It will reduce fraud in insurance claims, which are more prevalent in reimbursement cases
• Better management of cost will enhance premium stability and affordability for customers
• It will encourage more people to avail of health insurance coverage, even in  the remote areas

How will the ‘Cashless Everywhere’ facility work for insurers and hospitals?

For the hospitals, there are certain criteria that they should satisfy to offer cashless treatment. This includes having at least 15 beds in the hospital. Also, the policyholder is expected to inform the insurer before 48 hours of a planned treatment/surgery and within 48 hours of an accidental hospitalization. Moreover, the hospital must send a request for cashless pre-authorization to the insurer to get the cashless activation process initiated. Once the authorization is approved, the hospital must submit an agreement, like a memorandum of understanding (MoU). After this step, cashless authorization will be given to the hospital even if it is not in the network of the insurance company. This facility can be used by remote hospitals with minimal technological access by simply sending an email with a cashless authorization request to the insurer.

Terms and Conditions for ‘Cashless Everywhere’

Below are some terms and conditions related to the Cashless Everywhere initiative:

• Service is not available at excluded providers/hospitals. Hence, policyholders need to check the link for the list of blacklisted hospitals on the respective website of their insurer
• It is very important to inform in advance as indicated in the post above about hospital admission to the insurer for processing the request
• The cashless facility will be available only when the hospital or the service provider accepts the authorization request 
• Policy terms and conditions shall apply

Claim Intimation Process

Below is the stepwise procedure to provide a cashless everywhere facility in a non-network hospital:

 1. Claim Intimation/Pre-Authorization:

The facility of cashless everywhere can be availed of only if the pre-authorization form reaches the insurance provider 48 hours before a planned treatment/procedure and within 24 hours of an Emergency admission to intimate the insurer.

2. Benchmarks of a Network Hospital for Cashless Service:

The Hospitals have to comply with Standards and Benchmarks for hospitals in the insurer’s network. Also, note that hospitals that are blacklisted or suspended by any insurer/government/TPA or if any fraudulent cases/activities have been reported against them will not be entertained

3. Rates/Packages:

The TPA should check if a hospital is already on the panel of any insurer/TPA. If so, TPA may try to get the agreed rates with that insurer/TPA. 

4. MOU with Hospital (Letter of Consent):

When the final approval of offering a cashless facility is received from a hospital, the TPA should get an MOU signed (temporary and valid for 3 months) by the TPA and the hospital. This MOU serves as a part of the claim documents at the time of processing the claim. Once the MOU expires, a fresh MOU should be issued for new transactions.