Insurance & TPA claims
Pre-authorisations, monthly claim batches, denials and remittance posting across all branches.
Receivable from payers
Rs 3.18 M
Pre-auths pending
7
Denial rate (90 d)
6.8%
Avg days to settle
41 d
Draft→Submitted→Approved/Partially approved/Rejected/QueryApproval code + expiry are required before the service is billed to the payer.
| PA no. | Patient / member | Payer | Service requested | Requested | Approved | Approval code | Expiry | Status | |
|---|---|---|---|---|---|---|---|---|---|
| PA-DHA-0042 | Hira Khan Member JGI-778120-02 · Spouse | Jubilee General via MedAssist TPA | Antenatal package (2nd trimester) + Anomaly scan | 48,500 | — | — | — | Submitted 11:05 · SLA 4 h | Open |
| PA-DHA-0041 | Abdul Rehman Engro Fertilizers · EMP-20931 | EFU Health | Day-care cystoscopy · Dr. Usman Tariq | 62,000 | 55,000 | EFU-AP-55190 | 20 Oct 2026 | Partially approved Rs 7,000 co-pay to patient | Open |
| PA-GLB-0019 | Sadia Akhtar Packages Ltd · EMP-4410 · Self | Adamjee Insurance | MRI lumbar spine (outsourced) | 22,000 | — | — | — | Query "Attach neurology note" | Reply |
| PA-DHA-0039 | Zainab Bibi State Life · Policy SL-GRP-1182 | State Life | Physiotherapy 10 sessions | 25,000 | 25,000 | SLIC-9921-OPD | 12 Nov 2026 | Approved | Open |
| PA-JHT-0011 | Kashif Mehmood Member EFU-55102-01 | EFU Health | Laser hair removal (cosmetic) | 36,000 | 0 | — | — | Rejected Cosmetic — excluded | Open |
| PA-DHA-0043 | Muhammad Imran Self-pay → converting to Jubilee | Jubilee General | Echo + TMT | 14,500 | — | — | — | Draft | Edit |
1Prepared
2Submitted
3Under review
4Settled / Partial / Denied
5Resubmitted
6Written off
| Batch | Payer | Period | Claims | Billed | Settled | Denied | Submitted | Status | |
|---|---|---|---|---|---|---|---|---|---|
| CLM-JUBILEE-202609-001 | Jubilee General (MedAssist TPA) | Sep 2026 | 214 | 1,284,600 | — | — | 05 Oct 2026 | Under review | Open |
| CLM-EFU-202609-001 | EFU Health | Sep 2026 | 96 | 512,300 | — | — | 06 Oct 2026 | Submitted | Open |
| CLM-JUBILEE-202608-001 | Jubilee General (MedAssist TPA) | Aug 2026 | 198 | 1,160,250 | 1,081,900 | 78,350 | 04 Sep 2026 | Partially settled | Open |
| CLM-SLIC-202607-001 | State Life | Jul 2026 | 41 | 268,400 | — | — | 06 Aug 2026 | Overdue · 68 d | Follow up |
| CLM-ADAMJEE-202608-002 | Adamjee Insurance | Aug 2026 (resub.) | 6 | 31,800 | 31,800 | 0 | 22 Sep 2026 | Settled | Open |
Batches are built automatically each month from invoices with a payer share; each claim carries the PA code, ICD-10 diagnosis, itemised lines and the stamped bill PDF.
Rs 78,350 denied in CLM-JUBILEE-202608-001
Fix and resubmit within 30 days of the remittance advice, or write off with owner approval.
| Claim line | Patient | Service | Amount | Denial reason | Action needed | Status | |
|---|---|---|---|---|---|---|---|
| INV-DHA-26-015201 / L2 | Nadia Perveen | Vitamin D (25-OH) | 3,200 | Not covered | Bill patient · send SMS payment link | Open | Transfer to patient |
| INV-DHA-26-015388 / L1 | Rizwan Haider | Day-care excision | 38,000 | No pre-auth | Request retro-approval with notes | Retro PA sent | Resubmit |
| INV-GLB-26-004412 / L3 | Usman Ali | Consultation (3rd in month) | 2,500 | Exceeds limit | Monthly OPD cap reached — co-pay | Open | Transfer to patient |
| INV-DHA-26-015470 / L1 | Bushra Naz | Ultrasound pelvis | 4,500 | Documents missing | Attach report PDF + referral slip | Ready | Resubmit |
| INV-JHT-26-002031 / L2 | Faisal Khan | Nebulisation x3 | 1,350 | Coding mismatch | Map to payer code NEB-01 | Open | Fix code |
Post remittance advice
Rs
Rs
Record any tax withheld by the payer for reconciliation.Auto-match result
193 / 198 matched| Result | Lines | Amount |
|---|---|---|
| Paid in full | 187 | 1,040,100 |
| Short-paid | 6 | 41,800 (of 52,300) |
| Denied | 5 | 0 (of 67,850) |
| Total posted | 198 | 1,081,900 |
| Payer | 0–30 d | 31–60 d | 61–90 d | 90+ d | Total | Mix |
|---|---|---|---|---|---|---|
| Jubilee General | 1,284,600 | 78,350 | 0 | 0 | 1,362,950 | |
| EFU Health | 512,300 | 96,400 | 22,100 | 0 | 630,800 | |
| State Life | 0 | 0 | 268,400 | 184,900 | 453,300 | |
| Adamjee Insurance | 88,200 | 0 | 0 | 0 | 88,200 | |
| Engro Fertilizers (corporate) | 341,600 | 0 | 0 | 0 | 341,600 | |
| Packages Ltd (corporate) | 0 | 71,500 | 0 | 227,300 | 298,800 | |
| All payers | 2,226,700 | 246,250 | 290,500 | 412,200 | 3,175,650 |
Bar shows share of balance under 60 days. Balances over 90 days auto-create a follow-up task for the panel officer and appear on the owner's daily WhatsApp summary.
Eligibility check
Last checked 11:02 · MedAssist TPA portalActive · Hira Khan · Group plan (Packages Ltd)
OPD cashless allowed · co-pay 10% · maternity rider active from 01 Mar 2026.
OPD annual limit
Rs 40,000
Rs 15,200 used · Rs 24,800 left
Maternity limit
Rs 150,000
Rs 18,000 used
Pre-auth needed for
Day-care, scans > Rs 10k, packages, physio
Top denial reasons · 90 days
Front desk sees a "pre-auth required" warning at billing when a payer rule matches the service.
| Service | Qty | Rate | Amount |
|---|---|---|---|
| Echocardiography | 1 | 8,500 | 8,500 |
| Treadmill test (TMT) | 1 | 6,000 | 6,000 |
| Requested | 14,500 | ||
Consultation note.pdfECG 13-Oct.pdf+ Attach
- Patient
- Abdul Rehman · Engro EMP-20931
- Requested
- Rs 62,000 · Day-care cystoscopy
- Approved
- Rs 55,000 · code EFU-AP-55190
- Valid until
- 20 Oct 2026
- Patient share
- Rs 7,000 (collected at admission)
10 Oct · 09:40
Submitted by Panel officer (Ayesha Bano)
10 Oct · 12:15
Query: "Share urine culture report"
10 Oct · 13:02
Reply with lab report LAB-26-118230
10 Oct · 16:30
Partially approved — consumables cap applied
Pre-submission scrub
182 claims ready · 4 missing PA code · 2 missing ICD-10 · 1 duplicate invoice line. Fix these before submission.