{"id":1044,"title":"Cashless Authorization Letter (Part-D)","purpose":"service","insurer":{"slug":"raheja-qbe-general-insurance","name":"Raheja QBE General Insurance Co. Ltd."},"source_pdf":"https://rahejaqbe.com/uploads/images/health-claim/pdf/Cashless_Authorisation_Form.pdf","sha256":"8b94b178f21b220842fd9938cdb157ddcdcff3aaec0be19b53c78fadbab1fafd","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is a cashless authorization letter issued by the insurer or TPA to authorize cashless hospital admission and treatment for the insured patient. It is filled by the insurer or TPA based on the pre-authorization request.","notes":["This form is issued by insurer or TPA after pre-authorization request.","Hospital must provide specified documents to support the claim.","Amounts and authorization details are filled by insurer or TPA.","The form includes terms and conditions that govern the cashless authorization."],"title":"Cashless Authorization Letter (Part-D)","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Authorization Details","fields":[{"help":"Quote this number for all further correspondence","type":"text","label":"Claim Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date: DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"Last date for valid admission","type":"date","label":"Authorization is valid for admission up to (date)","options":[],"required":null,"pdf_field":""},{"help":"Hospital name and address","type":"text","label":"ABC Hospital Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Insurance Company:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of TPA:","options":[],"required":null,"pdf_field":""},{"help":"Name of the policyholder","type":"text","label":"Proposer Name:","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured patient","type":"text","label":"Patient's Member:","options":[],"required":null,"pdf_field":""},{"help":"Patient's ID number","type":"text","label":"ID/TPA/Insurer Id of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Relationship of patient to proposer","type":"text","label":"Relation with Proposer:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Rohini Id:","options":[],"required":null,"pdf_field":""},{"help":"Date of pre-authorization request","type":"date","label":"This has reference to the pre-authorization request submitted on","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Patient Name:","options":[],"required":null,"pdf_field":""},{"help":"Patient's age","type":"number","label":"Age :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender :","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Insurance policy number","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Expected Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Policy start and end dates","type":"text","label":"Policy Period:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Expected Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Room category requested","type":"text","label":"Room category:","options":[],"required":null,"pdf_field":""},{"help":"Room category allowed as per policy terms","type":"text","label":"Eligible Room Category as per T&C of Policy Contract:","options":[],"required":null,"pdf_field":""},{"help":"Number of days expected in hospital","type":"number","label":"Estimated length of stay:","options":[],"required":null,"pdf_field":""},{"help":"Preliminary diagnosis","type":"text","label":"Provisional Diagnosis :","options":[],"required":null,"pdf_field":""},{"help":"Treatment planned","type":"text","label":"Proposed line of treatment:","options":[],"required":null,"pdf_field":""},{"help":"Date and time of authorization","type":"date","label":"Authorization Details :- Date & Time","options":[],"required":null,"pdf_field":""},{"help":"Authorization reference number","type":"text","label":"Reference number","options":[],"required":null,"pdf_field":""},{"help":"Authorized amount","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"Authorization status","type":"text","label":"Status","options":[],"required":null,"pdf_field":""},{"help":"Total amount authorized in numbers and words","type":"amount","label":"Total Authorized amount :- Rs ( In words )","options":[],"required":null,"pdf_field":""},{"help":"Any remarks related to authorization","type":"text","label":"Authorization Remarks :","options":[],"required":null,"pdf_field":""},{"help":"Tariff agreed with hospital","type":"text","label":"Hospital Agreed Tariff:","options":[],"required":null,"pdf_field":""},{"help":"Package rate if applicable","type":"amount","label":"I. Package case Agreed Package Rate","options":[],"required":null,"pdf_field":""},{"help":"Daily charges for non-package cases","type":"amount","label":"II. Non-package Case: i. Room Rent/day ii. ICU Rent/day iii. Nursing Charges/day Iv. Consultant Visit Charges/day v. Surgeon's fee/OT/Anaesthetist vi. Others (specify) -------","options":[],"required":null,"pdf_field":""},{"help":"Summary of billing and deductions","type":"amount","label":"Authorization Summary: Total Bill Amount : (INR) *Other Deductions : (INR) (At the time of Final Authorization) Discount : (INR) (At the time of Final Authorization) Co-Pay : (INR) Deductibles : (INR) Total Authorised Amount: : (INR) Amount to be paid by Insured : (INR)(At the time of Final Authorization)","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other deductions with columns: S.no, Description, Bill Amount, Deducted Amount, Admissible Amount, Deduction Reason","type":"table","label":"*Other Deduction Details: S.no Description Bill Amount Deducted Amount Admissible Amount Deduction Reason","options":[],"required":null,"pdf_field":""}],"filled_by":"insurer or TPA"},{"title":"Documents to be provided by the hospital in support of the claim","fields":[{"help":"Attach detailed discharge summary and all hospital bills","type":"attachment","label":"Detailed Discharge Summary and all Bills from the hospital","options":[],"required":null,"pdf_field":""},{"help":"Attach cash memos with prescriptions","type":"attachment","label":"Cash Memos from the Hospitals / Chemists supported by proper prescription.","options":[],"required":null,"pdf_field":""},{"help":"Attach diagnostic test reports and receipts with doctor's recommendation","type":"attachment","label":"Diagnostic Test Reports and Receipts supported by note from the attending Medical Practitioner / Surgeon recommending such Diagnostic supported by note from the attending Medical Practitioner / Surgeon recommending such diagnostic tests.","options":[],"required":null,"pdf_field":""},{"help":"Attach surgeon's certificate and bills","type":"attachment","label":"Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt.","options":[],"required":null,"pdf_field":""},{"help":"Attach medical certificates on patient's condition and discharge advice","type":"attachment","label":"Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Diagnostic Test Reports and Receipts supported by note from the attending Medical Practitioner / Surgeon recommending such diagnostic tests","Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge"],"declarations":["Cashless authorization is based on information in the pre-authorization form and is void if there is misrepresentation or discrepancy in documents.","KYC details of proposer/employee/beneficiary are mandatory for claim payout above Rs 1 lakh.","Network provider shall not collect amounts in excess of agreed package rates except for non-admissible costs.","Network provider shall not recover amounts from deposits except for non-admissible costs.","Insurer/TPA reserves the right to recover unauthorized excess amounts from the network provider.","Treatment by a non-empaneled doctor requires specific consent of the policyholder.","Differential costs borne by policyholder may be reimbursed subject to policy terms."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customercare@rahejaqbe.com","label":"Service mail ID","level":null,"hours":"Monday to Saturday from 9 AM to 8 PM","applies_to":"all","source_url":"https://rahejaqbe.com/grievance-redressal","quote":"Commercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolicy\nServicing\nLet us call you","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"18001027723","label":"Toll Free","level":null,"hours":"Monday - Saturday, 9 AM - 8 PM","applies_to":"all","source_url":"https://rahejaqbe.com/contact-us","quote":"ims!\nExplore\nCommercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolic","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"complaintsofficer@rahejaqbe.com","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://rahejaqbe.com/grievance-redressal","quote":"isfied with the response received and need further assistance, please email our Grievance Redressal   \n\t\t\t\t  Officer at\ncomplaintsofficer@rahejaqbe.com\nYou can also\nClick​ here\nto login to Bima Bharosa Portal of IRDAI to register your   \n\t\t\t\t  grievance\nIf even this leav","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"The Grievance Cell, Raheja QBE General Insurance Co. Ltd., Fulcrum, 501 & 502, A wing, 5th Floor, International Airport project road, Sahar, Andheri East, Mumbai – 400059","label":"Grievance Cell Address","level":null,"hours":null,"applies_to":"all","source_url":"https://rahejaqbe.com/uploads/images/two-wheeler-package/pdf/download/tw-package-policy-wording-v02.pdf","quote":"e helpline 1800-102-7723 (9 am to 8 pm, Monday to Saturday) Email us at complaintsofficer@rahejaqbe.com\nWrite to us at: The Grievance Cell, Raheja QBE General Insurance Co. Ltd., Fulcrum, 501 & 502, A wing, 5th Floor, International Airport project road, Sahar, Andheri East, Mumbai – 400059\n\nOffice of the Ombudsman | Contact Details | Jurisdiction\nAhmedabad | Office of the Insurance Ombudsman, Jeevan Prakash","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Raheja QBE General Insurance Company ltd Fulcrum, 501 & 502, A wing, 5th Floor, International Airport project road, Sahar, Andheri East, Mumbai-400059.","label":"Registered Office Address","level":null,"hours":null,"applies_to":"all","source_url":"https://rahejaqbe.com/grievance-redressal","quote":"int\nclick here\nOr Reach us at:\n18001027723\n,\nMonday to Saturday from 9 AM to 8 PM,\nOr email:\ncustomercare@rahejaqbe.com\nRaheja QBE General Insurance Company ltd Fulcrum, 501 & 502, A wing, 5th Floor, International Airport project road, Sahar, Andheri East, Mumbai-400059.\nIf you do not get a response within 5 working day or you are not satisfied with the response received and need further","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"18001027723","label":"Toll free helpline","level":null,"hours":"Monday to Saturday from 9 AM to 8 PM","applies_to":"all","source_url":"https://rahejaqbe.com/grievance-redressal","quote":"ims!\nExplore\nCommercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolic","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-102-7723","label":"Toll free helpline","level":null,"hours":"9 am to 8 pm, Monday to Saturday","applies_to":"all","source_url":"https://rahejaqbe.com/uploads/images/two-wheeler-package/pdf/download/tw-package-policy-wording-v02.pdf","quote":"ces and wish to lodge a complaint, please feel free to contact us through below channels:\nCall us at toll free helpline 1800-102-7723 (9 am to 8 pm, Monday to Saturday) Email us at complaintsofficer@rahejaqbe.com\nWrite to us at: The Grievance Cell, Rahe","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/raheja-qbe-general-insurance/1044-cashless-authorization-letter-part-d"}