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-24117
Patient
Lakshmi Devi, 61
TPA / Payer
PMJAY / Ayushman Bharat
Policy / Card
PMJAY-UP-7781203
Procedure
Cataract (Phaco with IOL) – SE003A
ICD-10
H25.1
Stay
2026-10-13 → 2026-10-14 (1d)
Pre-auth
₹15,000
Final bill
₹15,000
100/100
Readiness verdict
Ready to Submit
| Checklist | Check | Result |
|---|---|---|
| Medical Necessity | ICD-10 codes consistent across documents | ✓ OK |
| Length of stay justified | ✓ OK | |
| 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 | |
| Rate & Capping | Room rent within policy cap | ✓ OK |
| Billed within package rate | ✓ OK | |
| Signatures & Stamps | Treating doctor signature on discharge summary | ✓ OK |
| Hospital seal / stamp on final bill | ✓ OK | |
| 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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