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    Hospital Document Tariff Statement (Mini SOC)

    Uploaded by

    Deepak Kaushik
    This document is a tariff statement from a hospital to an insurance company listing proposed charges for various inpatient and outpatient medical services. It includes room rates, ICU charges, professional fees, operation theater costs, lab tests, imaging, and other miscellaneous items. The hospital is asked to provide charges for all listed facilities or note those not applicable. The charges will be used to determine guideline rates but do not represent agreed prices, and the rates will be valid for three years if accepted by both parties.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Hospital Document Tariff Statement (Mini SOC)

    Uploaded by

    Deepak Kaushik
    1K views1 page
    This document is a tariff statement from a hospital to an insurance company listing proposed charges for various inpatient and outpatient medical services. It includes room rates, ICU charges, professional fees, operation theater costs, lab tests, imaging, and other miscellaneous items. The hospital is asked to provide charges for all listed facilities or note those not applicable. The charges will be used to determine guideline rates but do not represent agreed prices, and the rates will be valid for three years if accepted by both parties.

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    Hospital_Document_Tariff_Statement_(Mini_SOC)

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    This document is a tariff statement from a hospital to an insurance company listing proposed charges for various inpatient and outpatient medical services. It includes room rates, ICU charges, professional fees, operation theater costs, lab tests, imaging, and other miscellaneous items. The hospital is asked to provide charges for all listed facilities or note those not applicable. The charges will be used to determine guideline rates but do not represent agreed prices, and the rates will be valid for three years if accepted by both parties.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views1 page

    Hospital Document Tariff Statement (Mini SOC)

    Uploaded by

    Deepak Kaushik
    This document is a tariff statement from a hospital to an insurance company listing proposed charges for various inpatient and outpatient medical services. It includes room rates, ICU charges, professional fees, operation theater costs, lab tests, imaging, and other miscellaneous items. The hospital is asked to provide charges for all listed facilities or note those not applicable. The charges will be used to determine guideline rates but do not represent agreed prices, and the rates will be valid for three years if accepted by both parties.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Star Health and Allied Insurance Company Limited

    Tariff Statement - Mini SoC ( )

    Hospital Name:
    Hospital Address:
    Owner Name:
    TPA Coordinator Name: Phone No:

    A Room Charges: Lab Charges


    No of Room Nursing 25 Serum Creatinine
    S.No. Category
    Beds Rent Charge 26 Serum Electrolytes
    1 General Ward 27 LFT
    Semi Private Room / Sharing 28 Thyroid Function Test
    2
    Non A/C 29 Lipid Profile
    3 Single Room Non A/C 30 Blood Widal
    4 Semi Private Room A/C 31 Smear for MP and MF - QBC
    5 Single Room A/C 32 Dengue NS1 Antigen
    6 Deluxe Room 33 Dengue Serology
    ICU Charges Including: Monitor, Pulse Oximeter, Syringe Pump & Infusion 34 CT /BT
    Pump, etc.,(All Inclusive Charges / Day) 35 Prothrombin Time
    7 ICU/ICCU/MICU 36 Partial Thromboplastin Time (aPTT)
    8 Neonatal ICU 37 Leptospira IgG
    B. Professional Charges: 38 Leptospira IgM
    9 Duty Doctor / Day 39 RA Factor
    10 Specialist/ Day 40 CRP
    C.Operation Theatre Charges : All Inclusive 41 Blood Uric Acid
    11 Operation Theatre/ Hour 42 Culture & Senstivity - Blood
    D.Imaging Investigations: 43 Culture & Senstivity - Urine
    12 USG - Pelvis 44 ABGA
    13 USG Whole Abdomen 45 HIV I & II
    14 ECG 46 HBsAg
    15 ECHO 47 Mantoux
    16 TMT 48 Sputum for AFB
    E.Lab Charges 49 Blood Typing & Cross Matching
    17 Blood Grouping And Rh Typing 50 Complete Urine Examination
    18 Complete Blood Count 51 Complete Stool Examination
    19 Platelet Count F.Others:
    20 Haemoglobin 52 Ventilator Charges per day
    21 Blood Sugar - Fasting / PP / Random 53 Dialysis Per Session
    22 HbA1C 54 Blood Transfusion Charges
    23 Glucose Tolerance Test 55 Registration Charges
    24 Blood Urea 56 Ambulance

    Note: a.) Kindly quote charges for all the facilities given above. For services / Infrastructure not available, Kindly mention ““Not Applicable “.
    b.)) The Charges which are not quoted would be considered as “Not Applicable“only
    “only.
    c.)) The charges submitted shall be utilized to arrive
    arrive at certain guideline charges and shall not be considered as agreed / accepted by us.
    d)) This is valid for a period of 3 years from the date of acceptance by both the parties
    parties.

    For Hospital: For Star Health and Allied Insurance Co. Ltd

    Name of the Designated Official:

    Date:

    Signature & Seal of Designated Official / Hospital

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