🛡️ Insurance · Flowchart
Cashless Health Claim Workflow
How a cashless hospital claim works between the hospital, the TPA and the insurer, from pre-authorisation to final settlement.
Drawing diagram…
What this diagram shows
- Pre-authorisation happens before treatment for planned admissions
- The TPA can ask for more documents before deciding
- Final settlement is checked against the approved amount
Prompt used
Cashless health insurance claim workflow: the hospital's insurance desk sends a pre-authorisation request to the TPA with diagnosis and cost estimate. The TPA checks the policy and asks for more documents if needed, then approves, partially approves or rejects. After discharge the hospital sends the final bill; the TPA audits it against the approval and the insurer pays the hospital. Non-payable items are collected from the patient.
Mermaid code
flowchart TD
A[Hospital sends pre-authorisation to TPA] --> B{Policy active and covered?}
B -->|No| R[Reject: patient pays and claims later]
B -->|Yes| C{Documents sufficient?}
C -->|No| D[TPA requests more documents] --> C
C -->|Yes| E{Decision}
E -->|Approve| F[Treatment and admission]
E -->|Partial| F
E -->|Reject| R
F --> G[Discharge: hospital sends final bill]
G --> H[TPA audits against approval]
H --> I[Insurer pays hospital]
H --> J[Patient pays non-payable items]Related templates
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