Shree Sai Nursing Home & Hospital
Plot 14, Station Road, Pune 411001 · ROHINI ID: 8900012345 · Ph: 020-2612 0000
Pre-Submission
TPA Clearance Slip
Claim ID
CLM-24091
Patient
Ramesh Kulkarni, 52
TPA / Payer
Star Health
Policy / Card
P/161114/01/2025/003412
Procedure
Laparoscopic Cholecystectomy
ICD-10
K80.2
Stay
2026-10-08 → 2026-10-12 (4d)
Pre-auth
₹85,000
Final bill
₹1,12,400
32/100
Readiness verdict
High Risk
| Checklist | Check | Result |
|---|---|---|
| Medical Necessity | ICD-10 codes consistent across documents | ✓ OK |
| Length of stay 4d exceeds expected 3d | ! WARN | |
| Documentation | Discharge Summary attached | ✓ OK |
| Final Hospital Bill attached | ✓ OK | |
| Doctor / Admission Notes attached | ✓ OK | |
| Lab / Investigation Reports attached | ✓ OK | |
| Pre-Auth Approval Letter attached | ✓ OK | |
| Missing: Histopathology Report | ✗ CRIT | |
| Missing: Pre-Auth Extension Approval | ✗ CRIT | |
| Rate & Capping | Room rent ₹4,500/day exceeds policy cap ₹4,000/day | ! WARN |
| Signatures & Stamps | Treating doctor signature on discharge summary | ✓ OK |
| Missing: Hospital seal / stamp on final bill | ✗ CRIT | |
| Patient / attendant signature on claim form | ✓ OK |
Audited by (Billing / TPA desk)
Name: ____________ Date: ________
Verified by (Medical Superintendent)
Name: ____________ Date: ________
QR / Hospital
Stamp
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