SMS — Insurance & TPA Management

↑ 12%

1,284

Total Claims (MTD)

847 approved · 218 pending

↑ 8%

₹4.2 Cr

Settlement Received

₹1.8 Cr outstanding

↑ 3%

218

Pending Authorization

62 critical · 156 routine

↓ 5%

97

Rejected Claims

7.6% rejection rate

↑ 4%

142

Active Corporates

₹86L corporate credit

↑ 6%

4.8 hrs

Avg Auth TAT

SLA target: 6 hrs

Analytics Claim Status Overview

1,284

Total

Approved847

Pending218

Rejected97

Under Query122

Jan

Feb

Mar

Apr

May

Finance Settlement Analytics

₹4.2Cr

Settled

₹1.8Cr

Outstanding

Recovery Rate 70%

TPA Recovery 84%

Corporate Billing 58%

18

Avg Days

34

Pending 30d+

6

Escalated

Corporate Outstanding Summary

Corporate	Amount	Days
Infosys Limited	₹4.8L	45d
TCS Healthcare	₹2.1L	28d
Wipro Corp Health	₹1.6L	22d
HCL Wellness	₹0.9L	14d
Tech Mahindra	₹0.6L	10d

Action Required Pending Claims — Immediate Attention

12 Critical

All

Critical

Under Review

Query Raised

Claim ID	Patient Name	TPA / Insurer	Authorized Amt	Requested Amt	Admission Date	TAT	Status	Action

Step 1Patient Insurance Lookup

Patient MRN / IP No. *

Patient Name *

Insurance Company / TPA *

Policy Number *

ID Card Number

Date of Admission

TPA InformationMedi Assist TPA Details

Active

TPA NameMedi Assist TPA Pvt Ltd

TPA IDTPA-0048

IRDAI LicenseTPA-0048/2004

Contact1800-200-4488

CoordinatorMs. Kavitha S.

SLA TAT6 Working Hours

Eligibility ResultPolicy Validation Status

Eligible

Policy HolderRajesh Nair

Policy TypeCorporate Floater

Sum Insured₹5,00,000

Utilized Amount₹1,80,000

Balance Available₹3,20,000

Valid From01 Apr 2025

Valid To31 Mar 2026

Pre-existing2yr Waiting

Co-pay Ratio10% on Room Rent

Network StatusIn-Network

Coverage Summary

✓

Room Rent

Single AC — ₹4,000/day

✓

ICU

Covered — No sub-limit

✓

Surgery

Covered as per tariff

✗

Dental

Not covered

~

Pharmacy

50% co-pay applies

✓

Diagnostics

Fully covered

Verification History Saved Verification Logs

Patient MRN	Patient Name	TPA / Insurer	Policy Number	ID Card Number	Admission Date	Status	Action

Active Request:

Authorization Lifecycle Pre-Auth Status — CLM-2025-4821

Query Raised

ClinicalClinical Details & ICD Codes

Treating Doctor *

Department

Admitting Diagnosis *

Planned Procedure

ICD-10 Codes

FinanceTreatment Estimate Calculator

Component	Estimated Cost (₹)
Room Rent & Nursing (Nursing + Stay)
ICU Charges
Surgical & OT Procedure Charges
Anesthesia Costs
Diagnostics & Lab Reports
Pharmacy & Consumables
Consultant Visits
Total Treatment Estimate	₹2,90,000

AUTHORIZED AMOUNT

₹2,40,000

UNFUNDED SHORTFALL

₹50,000

CommunicationQuery & Activity Timeline

218

Pending Approvals

34

SLA Warning Breaches

67

Open Active Queries

12

Escalated Tickets

SLA MonitoringTPA SLA Performance

QueuePending Approvals Queue

218 Pending

Claim ID	TPA Company	TAT Hours	Status Badge	Actions

Corporate Master

Employee Eligibility

Tariff Management

Invoice Summary

Corporate Name	City Location	Employees	Credit Limit	Outstanding Balance	Last Invoice	Status	Actions

Select Corporate Partner

Employee ID

Employee Name

Select Corporate Tariff Sheet

₹18.4L

Month Invoiced

₹4.8L

Overdue Balance

₹86.4L

YTD Total Billed

94%

Collection Rate

Invoice No.	Corporate Partner	Billing Period	Invoice Amount	Due Date	Invoice Status	Action

Track Claim ID:

Under Query

LifecycleClaim Progress Timeline

Additional RequestEnhancement Form

Select Active Claim *

Reason for Enhancement *

Original Auth Amount

Additional Amount Requested (₹) *

Clinical Justification *

UtilizationUtilization Summary

₹2,40,000

Authorized

₹1,84,000

Utilized

₹56,000

Remaining

Utilization Rate 77%

Revised Estimate Upload

Upload Revised Estimate

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Log Enhancement History Logs

Request ID	Claim ID	Reason Category	Original Auth	Additional Amount	Status	Action

Active Claim Selector Final Bill Details

Bill Summary Final Bill

Ready for Settlement

₹0

Total Bill

₹0

Insurance Payable

₹0

Patient Payable

₹0

Settled Amount

Covered vs Non-Covered Split Percentage

UploadUpload Documents

Claim / Patient ID *

Document Category *

Drag & Drop Files Here

Supports PDF, JPG, PNG, DOCX — Max 10MB per file

or browse to upload

RepositoryUploaded Documents

0 Files

Analytical Filters:

4.8 hrs

Avg Auth TAT

Target SLA: 6 hrs

₹6.2 Cr

Insurance Revenue

May Total Invoiced

7.6%

Rejection Rate

From submitted requests

18d

Avg Settlement Days

Target SLA: 21 days

TAT AnalysisClaim TAT Report by TPA

TPA	Avg Auth TAT	Avg Settlement	SLA Success	Status

Rejection AnalyticsTop Rejection Reasons

Operations Dashboard

Insurance Verification

Coverage Summary

Pre-Authorization Management

ICD-10 Codes

TPA Management Console

Corporate Management

Claim Tracking

Enhancement Requests

Revised Estimate Upload

Upload Revised Estimate

Billing & Settlement

Covered vs Non-Covered Split Percentage

Document Management

Drag & Drop Files Here

Reports & Analytics