Pending Draft Cases
| Reference Number | Case Inception Date | Case Age | Patient Name | Patient Phone | Complainant Name | Manager Name | CP Name | Company | Claim Number | Claim Amount | Operation Officer | Medical Officer | Case Status | Action | Action | Action | Action | Action | Action | Action | Action |
|---|
Case Report
[Case Number]
[Case Handler]
[Initial Case Date]
[Case status]
[Remarks]
[Initial Case Date]
[Case status]
[Remarks]
[Initial Case Date]
[Case status]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[Remarks]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
[None]
INITIAL CLAIM ASSESSMENT SHEET
NAME OF PATIENT: [Patient Name]
NAME OF COMPLAINANT: [Complainant Name]
RELATIONSHIP: [Relation]
Type of Claim / Rejection / Deduction: [Type]
Claim Amount:[Amount]
POLICY NUMBER: [Policy Number]
CLAIM NUMBER: [Claim Number]
DATE OF INCEPTION OF FIRST POLICY: [Date]
COMPANY NAME: [Company Name]
HOSPITAL NAME: [Hospital Name]
DOA: [Date of Admission] DOD: [Date of Discharge]
DIAGNOSIS: [Policy Number]
PATIENT COMPLAINS DURING ADMISSION: [Complaints]
REJECTION REASON DATED: [Rejection Reason] [Reason]
COMMENTS GIVEN BY: [Comments]
