Get Reimbursement Form B 2013_r1 - Bajaj Allianz

Filling out the Reimbursement Form B 2013_r1 from Bajaj Allianz online can be straightforward if you follow the correct procedures. This guide will help you navigate each section of the form with clarity and ensure that you provide all necessary information accurately.

Follow the steps to complete the reimbursement form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the details of the hospital. This section includes the hospital name, hospital ID, type of hospital (in-network or non-network), and the treating doctor's name and qualifications. Ensure that all entries are completed in block letters.
3. Next, proceed to SECTION A, where you enter the patient's admitted details. This includes the name, IP registration number, gender, age, date of birth, dates and times of admission and discharge, type of admission, and total claimed amount.
4. In SECTION B, provide the details of the ailment diagnosed. This requires entering ICD 10 codes for the primary diagnosis, additional diagnoses, co-morbidities, and any procedures performed. Check if pre-authorization was obtained and include the corresponding numbers.
5. If applicable, move to SECTION C to provide information linked to hospitalization due to injury or substance abuse and the relevant documentation or reports.
6. In SECTION D, ensure to check the list of claim documents submitted with your application. This is crucial for the successful processing of your claim.
7. If your hospital is non-network, complete SECTION E with the necessary details such as hospital address, registration number with state code, and PAN.
8. Finally, review and read the declaration in SECTION F carefully. Fill in the date and place, then sign and stamp the form before submission.
9. Save your changes, download the filled form, print it, or share it as required for submission.

Begin filling out your reimbursement form online today for a seamless experience.