Final Approval Authorization Letter

Date: 10 Jan 2024 16:16:02

To,
Administrator
Fortis Hospital, Rajaji Nagar
111,West Of Chord Road Opp Rajajinagar 1St Block Junction

Rohini ID: 8900080189737

With reference to your request for cashless pre-authorization with Pre auth ID 202400037002 and pre-auth claim number
202400037002 for SURYAKANTH ., we wish to inform you that we hereby authorize INR 62,394.0 for treatment of
SURYAKANTH . against an estimated cost of INR 73,987.0 Here is everything you need to know about your pre-authorization
request:

Beneficiary Details
MPH name/Proposer BANGALORE METRO RAIL CORPORATION
MPH Number D117894106
name LIMITED
Policy holder
Patient UHID 9211 UMESH .
Name
Policy number D117902841 Member ID N075435538927050
Insured/Patient name SURYAKANTH . Gender MALE
Policy holder emp
Date of Birth 1966-01-01 20651
ID

Treatment Details
Final Diagnosis Non healing ulcer , calcaneal spur ,varicose vein of left leg
Procedure Name Other
Date Of Admission 2024-01-09
Treating Doctor name DR VASUDEV
Date of Discharge 2024-01-10
Room Type MULTI BED

Authorization details (amount in INR)

Requested Authorized
Status Pre auth type Approved Date
amount amount
Pre-authorization Initial 2024-01-08
Approve 1,10,000.0 47,000.0
Approval 18:38:20
Pre-authorization Final 2024-01-10
Approve 73,987.0 62,394.0
Approval 16:16:01

All in all, you will receive (total authorized amount) INR 62,394.0 for

Hospital Remarks
NA

Authorization Summary (amount in INR)

Total bill amount 73,985.0
Excess tariff 100.0
Total deductions* 8,369.0
Hospital discount 3,119.0

THIS IS A SYSTEM GENERATED CORRESPONDENCE HENCE DOES NOT REQUIRE SIGNATURES

Go Digit General Insurance Limited | Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru
560095 | CIN: U66010PN2016PLC167410
Website: www.godigit.com Toll Free: 1800-258-4242 Email: Healthcashless@godigit.com
 Additional discount 0.0

Negotiation discount
Total Proportionate Capping 0.0
Copay amount 0.0
Deductible amount 0.0
Total authorized amount 62,394.0
Amount to be paid by Insured 8,369.0
Premium EMI Recovery Amount 0.0
Excess SI Deduction 0.0

* In case you are wondering, how did we calculate deductions (amount in INR)

These are certain expenses which are non-payable by the insurer as per your policy agreement.
Here is the list of all such expenses for your quick reference.

Non-
Bill Expense Bill
payable Disallowed reasons
number Category amount
amount
Consultation
2251 1380 0 NA
visit charges
Miscellaneous TPA PROCESSING CHARGES-940,CSSD/Biomedical Waste charges-
2251 1990 1240
charges 150,Patient Linen & Laundry Charges-150,
2251 OT Charges 14160 0 NA
SURGEON GOWN DHRITHI SURGICAL SOLUTIONS-350,DRAPE
DRAW SHEET.,XL,WITH ADHESIVE.,SHI MEDIWEAR-100,ECG
ELECTRODE ..PAEDIATRIC.IE420100091.3 INDIA-87,SYRINGE
DISPOSABLE,DISPOVAN,2 ML W/O NEEDLE,PRD00467,LUER
MOUNT,HMD-14.2,SYRINGE DISPOSABLE,DISPOVAN,S ML W/O
NEEDLE,LUER MOUNT PRD00469,HMD-17.6,SYRINGE
DISPOSABLE,UNOLOK,10 ML W/O NEEDLE,PRD00613,LUER
LOCK.HMD-11,SYRINGE DISPOSABLE,UNOLOK,201 ML W/O
Medicine &
NEEDLE,PRD00614,LUER LOCK,HMD-39.6,NEEDLE
2251 Consumable 3669 1691
DISPOSABLE,GLIDE,18G X1.5,302032.,BECTON DICKINSON-
charges
9,SYRINGE DISPOSABLE,DISPOVAN,5 ML W/O NEEDLE.LUER
MOUNT,PRD00469,HMD-17.6,SYRINGE DISPOSABLE,UNOLOK,10 ML
W/O NEEDLE,PRD00613,LUER LOCK,HMD-22,NEEDLE
STERILE,GLDE.,24GX1TE,3029 05,NEEDLE,BECTON DICKINSON-
9,NEEDLE DISPOSABLE,GLIDE,18G X1.5,302032.. BECTON
DICKINSON-12,GENERAL DRAPE KIT DHRITHI SURGICAL
SOLUTIONS-700,OXYGEN FACE MASK,FLEXI MASK,ADULT,GS 2020.
ROMSONS-302,
NEEDLE DISPOSABLE,GLIDE,18G (1.5,302032,,BECTON DICKINSON-
24,SYRINGE DISPOSABLE,UNOLOK,10 W/O NEEDLE,PRD00613,LUER
Medicine &
LOCK,HMD-33,SYRINGE DISPOSABLE,DISPOVAN,2 W/O
2251 Consumable 1458 680
NEEDLE,PRD00467,LUER MOUNT,HMD-21.3,BODY WIPES (PACK OF
charges
10),GLIDER AQUA BATH,240MM X300MM....AICARE INDUSTRIES
PVT LTD-530,UNDER PAD,,60X90CM,GS 8418-1,ROMSONS-72,
Package
2251 9440 0 NA
Charges
Anaesthetists
2251 7210 0 NA
fee
Duty Doctor / RESIDENT MEDICAL OFFICER (RMO)-600,RESIDENT MEDICAL
2251 1300 1200
RMO charges OFFICER (RMO)-600,
Medicine &
2251 Consumable 2868 0 NA
charges

THIS IS A SYSTEM GENERATED CORRESPONDENCE HENCE DOES NOT REQUIRE SIGNATURES

Go Digit General Insurance Limited | Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru
560095 | CIN: U66010PN2016PLC167410
Website: www.godigit.com Toll Free: 1800-258-4242 Email: Healthcashless@godigit.com
 Procedure
2251 Charges 5528 209 CANNULIZATION | 226287-209,

Admission
2251 570 570 ADMISSION CHARGES-520,ADMISSION KIT-50,
charges
Registration
2251 120 120 REGISTRATION CHARGES-120,
Charges
Investigation
2251 3420 0 NA
Charges
Investigation
2251 8780 0 NA
Charges
IV CANNULA,VENFLON PRO SAFETY,18G,393247,SAFETY,B ECTON
DICKINSON-485,NEEDLE DISPOSABLE,GLIDE,18G
X1.5,302032.,BECTON DICKINSON-9,NEEDLE
STERILE,GLIDE,,24GX1TE,3028 05,NEEDLE,BECTON DICKINSON-
4.5,SYRINGE DISPOSABLE,UNOLOK,10 W/O
Medicine &
NEEDLE,PRD00613,LUER LOCK,HMD-11,SYRINGE
2251 Consumable 2018 813
DISPOSABLE,DISPOVAN,2 ML W/O NEEDLE,PRD00467,LUER
charges
MOUNT,HMD-14.2,EXAMINATION GLOVES UNSTERILE,NITREX
NITRILE MEDIUM-PACK OF ONE RAMSON HEALTH CARE-
160,SURGICAL MASK ,GURAD WELL,3 PLY LOOP MASK,GS
6100,MELT BELOWN FILTER.ROMSONS-10,EXAMINATION GLOVES
UNSTERILE,NITREX NITRILE MEDIUM PACK OF-120,
SURGICAL BLADE,LISTER,NO 15,NA,NA,MAGNA MARKETING-
6,PLAIN SHEET MEDIUM,120CM) X 150CM,,MATA ENTERPRISES-
90,SPINAL NEEDLE.QUINCKE,26GX3.5.40 24.,BECTON DICKINSON-
237,EXAMINATION GLOVES UNSTERILE,NITREX-,NITRILE MEDIUM-
PACK OF ONE RAMSON HEALTH CARE-200,CREPE
Medicine &
BANDAGE,LEUKOCREPE,15C MX4MTS,DRESSING,72992- 03,ESSITY
2251 Consumable 2294 966
INDIA PRIVATE LIMITED-128,ROLLER BANDAGE CLOTH 6" 15CM X
charges
10 MTR, LOTUS SURGICAL-45,DISPOSABLE NURSES
(BUFFENET)CAP LOCAL-50,CAPS SURGEON,BOX OF DO.,SURGEON-
30,SURGICALMASK,GURAD WELL,3 PLY LOOP MASK,GS 6100,MELT
BELOWN FILTER,ROMSONS-100,EXAMINATION GLOVES UNSTERILE
NITRILE MEDIUM- PACK OF ONE RAMSON HEALTH CARE-80,
2251 Nursing fees 2100 0 NA
2251 MRD Charges 880 880 Medical Records Management Charge-880,
Room
2251 4800 0 NA
Charges
Grand
73985 8369
Total

Refer the link for Non-Payable items : List of Non-medical Items

Terms and conditions for authorization

1. Cashless authorization letter issued is based on information provided in preauthorization form by the
hospital. In case of misrepresentation/concealment of material facts, or any difference/deviation/
discrepancy in information provided by hospital/customer is observed in discharge summary / IPD
records then cashless authorization stand null & void. At any point of claim processing, Digit reserves
right to raise request for additional information for any other document to ascertain the admissibility of
claim.
2. KYC (Know your Customer) card details of proposer/employee/beneficiary are mandatory for claim
payout above INR.1 Lakh.
3. Network provider/Hospital shall not collect any additional amount from Digit customer apart from the
agreed tariff rates between hospital and Digit except cost towards non admissible amounts mentioned
in the letter under deductions section mentioned above (this includes additional charges due to opting
higher room rent than eligibility/choosing separate line of treatment which is not envisaged/considered
in package and discount agreed by the hospital for Digit customers).
4. Network provider/Hospital shall not make any recovery from the deposit amount collected from the

THIS IS A SYSTEM GENERATED CORRESPONDENCE HENCE DOES NOT REQUIRE SIGNATURES

Go Digit General Insurance Limited | Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru
560095 | CIN: U66010PN2016PLC167410
Website: www.godigit.com Toll Free: 1800-258-4242 Email: Healthcashless@godigit.com
 insured except for the cost towards non admissible amounts (including additional charges due to opting
higher room rent than eligibility/choosing separate line of treatment which is not envisaged/considered
in Package/ agreed tariff).
5. In the event of unauthorized recovery of any additional amount from the insured more than Agreed
package Rates, Digit reserves the right to recover the same or get the same refunded to the policy
holder from the network provider via recovery of the additionally collected amount from payable amount
of current or other payable claims made by the network provider/hospital and/or take necessary action
as provisioned under the MOU
6. Where treatment / procedure to be carried out by a Doctor/Surgeon of insured's choice (not empaneled
with the Hospital) network provider/hospital may give treatment after obtaining specific consent of the
policyholder.
7. Differential Costs borne by policyholder may be reimbursed by insurers subject to the terms and
conditions of the policy.

For the hospital team: Cashless document submission checklist

1. Govt valid Photo ID proof of primary insured/policy holder and insured admitted (Driving license, Voter ID card,
Ration card)
2. PAN Card of Primary beneficiary (if approved/claimed amount is >INR.1 Lakh)
3. Discharge Summary (Mandatory)
4. Final Bill (Mandatory)
5. All investigation reports (Lab reports, XRAY, CT scan, MRI)
6. Invoice sticker
7. Biopsy Report (If applicable)
8. Any other document as request by Digit

Please share the Final Bill within 7 days of discharge of the patient.

Please ensure that final hospital bill is generated in name of “Go Digit General Insurance Limited".

For any query or clarification, you can call us at 1800-258-4242 or write to us at Healthcashless@godigit.com.

If you are a senior citizen, please write to us at Seniors@godigit.com

Always count on us when you count your well-wishers!

Warm Regards,
Team Digit

THIS IS A SYSTEM GENERATED CORRESPONDENCE HENCE DOES NOT REQUIRE SIGNATURES

Go Digit General Insurance Limited | Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru
560095 | CIN: U66010PN2016PLC167410
Website: www.godigit.com Toll Free: 1800-258-4242 Email: Healthcashless@godigit.com