Tell me about how to fill it

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Here is a complete guide on how to fill Part B of this health insurance claim form. This part must be filled by the Treating Doctor or Hospital only.

Part B - Health Insurance Claim Form: How to Fill

Hospital/Nursing Home Details (Top Section)

Field	What to Enter
Name of Hospital/Nursing Home	Full registered name of the hospital
Address	Complete address
City, State, Pincode	Location details
Telephone / Mobile No.	Hospital's contact numbers
ROHINI ID*	Hospital's ROHINI (Registry of Hospitals in Network of Insurance) ID - mandatory
Type of Hospital	Tick Network or Non Network. If Non Network, also fill Registration No. with State Code, PAN, and Number of Inpatient Beds
Facilities Available	Tick OT (Operation Theatre) and/or ICU if available

B2 - Attending Doctor Details

Field	What to Enter
Name	Full name of the treating doctor/surgeon
Qualification	Degrees (e.g., MBBS, MD, MS)
Registration No.	Medical council registration number
Telephone / Mobile No.	Doctor's contact details

B3 - Patient Details (partially filled in your form)

Field	What to Enter	Already Filled
Name of Patient	Full name as per ID	RAMME GARG
IP Registration No.	In-patient registration number	881
Gender	Tick M or F	F (Female)
Age	In years and/or months	58 Years
Date of Birth	DD/MM/YYYY	Blank - needs to be filled
Date of Admission	DD/MM/YYYY and time	07/07/2026, 23:31
Date of Discharge	DD/MM/YYYY and time	09/07/2026, 10:30
Type of Admission	Tick one: Emergency / Planned / Day Care / Maternity	Emergency ticked
Type of Treatment	Tick one: Surgical / Multiple Surgical / Medical	Medical Treatment ticked
If Maternity	Fill date of delivery and Gravida Status (G/P/A/L) only if maternity case	Not applicable here
Premature Baby	Yes or No - only if maternity	Not applicable here
Status at Discharge	Tick: Discharge to home / Another hospital / Deceased	Needs to be filled
Total Claimed Amount (₹)	Enter the total hospital bill being claimed	Needs to be filled

B4 - Procedure Details

Field	What to Enter
Pre-authorization obtained	Tick Yes or No. If Yes, write the Pre-authorization Number
If authorization not obtained	Give reason (e.g., emergency admission)
Date of disease/injury first detected	DD/MM/YYYY - when the illness was first diagnosed
If Injury	Tick cause: Self-inflicted / Road accident / Substance abuse / Others
If Medico-Legal (MLC)	Tick Yes/No. If Yes, tick if reported to police and attach MLC + FIR reports
FIR No.	Fill only if an FIR was filed
Substance abuse test	Tick Yes/No if injury was alcohol/substance related

B5 - Mandatory if Policy is NOT from Employer

Fill this section if the patient has an individual/retail health policy (not a group/employer policy):

Row	What to Enter
A(i) Primary Diagnosis	Main diagnosis with ICD-10 code (e.g., J18.9 - Pneumonia)
A(ii) Additional Diagnosis	Any secondary conditions with ICD-10 codes
A(iii) Procedure Diagnosis	Procedure code (ICD-10-PCS) if a procedure was done
B	Nature of surgery/treatment given
C	Date of first consultation before this hospitalization
D	Presenting complaints when patient was admitted
E	Past medical history and duration; attach past consultation papers
F	Was patient under alcohol influence at admission? (Yes/No)
G	Is this ailment a complication of a pre-existing disease? Specify disease and details
H	Is the disease/disorder congenital? (Yes/No)
I	Total number of in-patient beds in hospital (including ICU)

Declaration & Signature (Bottom)

The hospital affirms all information is true and correct.
Affix the rubber stamp of the hospital with Registration Number.
Fill in the Date (DD/MM/YYYY).
The treating doctor must sign and affix their seal.

Key Points to Remember

Part B is only for the hospital/doctor - the patient should not fill this part.
The ROHINI ID is mandatory for network hospital claims.
ICD-10 codes in B5 must be accurate - wrong codes can delay or reject the claim.
For emergency admissions (like this case), mention the reason pre-authorization was not obtained in B4.
Attach all supporting documents: discharge summary, bills, investigation reports, MLC/FIR if applicable.
The doctor's seal and signature are mandatory for the claim to be processed.

Pt. Falls on ground and injured so what is the medical term for this injury

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Searching the Web

medical term for patient falls on ground injury ICD-10 code

Finding Sources

Here is a complete breakdown of the medical terminology used when a patient falls on the ground and sustains an injury:

Medical Terms for "Patient Falls on Ground and Gets Injured"

1. Primary Medical Term

Ground Level Fall (GLF)

This is the standard clinical term used in emergency medicine and hospital settings.
It means the patient fell from their own standing/sitting height to the ground - NOT from a height (like a ladder or stairs).
Also called a "Fall on Same Level" or "Low-Energy Fall"

2. Type of Trauma

Term	Meaning
Blunt Trauma	Injury from impact with the ground (no penetration)
Low-Energy Trauma	A fall from standing height - less force than high-energy (car accident, fall from height)
Accidental Fall	Unintentional fall - most common category
Mechanical Fall	Patient tripped or lost balance without an underlying medical cause
Syncopal Fall	Patient fell due to loss of consciousness (blackout)

3. ICD-10 Codes (used in insurance forms like the one in your image)

ICD-10 Code	Description
W18.30XA	Fall on same level, unspecified - initial encounter (most common)
W19.XXXA	Unspecified fall, initial encounter
W18.31XA	Fall on same level due to stepping on an object
W01.0XXA	Fall on same level from slipping, tripping, stumbling
Z91.81	History of falls (used as additional/secondary code)

For the insurance claim form (B4 section - "Date of injury/disease first detected" and "If Injury, give cause"), the doctor would tick "Others" or "Self-inflicted" is NOT appropriate here - a ground-level fall would be documented under "Others" with the description written as "Ground Level Fall" or "Accidental Fall."

4. Common Injuries from Ground Level Falls

Injury Type	Medical Term
Broken bone	Fracture (e.g., hip fracture, wrist fracture - Colles' fracture)
Head injury	Traumatic Brain Injury (TBI) / Head contusion
Bruising	Contusion / Ecchymosis
Skin wound	Laceration (cut) or Abrasion (scrape)
Joint injury	Sprain (ligament) or Strain (muscle/tendon)
Hip injury	Neck of femur fracture - very common in elderly falls
Shoulder injury	Proximal humerus fracture
Wrist injury	Distal radius fracture (Colles' fracture)

5. In the Context of Your Claim Form (B4 Section)

When filling the injury cause in Section B4, the doctor should write:

"Accidental ground level fall" or "Fall on same level"
Tick "Others" under "If Injury, give cause"
Write the description in the blank: "Accidental fall on ground level"
Tick "No" for Self-inflicted, Road traffic accident, and Substance abuse
Tick "No" for Medico-legal (unless there is suspicion of foul play)

In short: The correct medical term to write on the form is "Accidental Fall" or "Ground Level Fall (GLF)", and the ICD-10 code is W18.30XA (for initial encounter).

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Pt. Is t2dm and injury of glf so what am I fill in these columns

analyse_media

I can see what's already filled and what's missing. Here is a complete guide on exactly what to write in every column for this patient (T2DM + Ground Level Fall):

Section B5 - Complete Fill Guide for This Patient

A) Diagnosis (ICD-10 Codes)

Sub-field	What to Write	Correct ICD-10 Code
i) Primary diagnosis	Ground Level Fall Injury with Lower Back Spasm	W18.30XA (Fall on same level, initial encounter)
ii) Additional diagnosis	Type 2 Diabetes Mellitus	E11.9 (T2DM without complications)
iii) Procedure diagnosis (ICD-10 PCS)	If only medical treatment given (no surgery)	Write: None / Not Applicable

⚠️ Currently the form has T2DM as primary and Lower Back Spasm as additional - but since the patient was admitted for the fall/injury, the primary diagnosis should be the fall injury, and T2DM should be the additional diagnosis. Consider correcting this.

B) Nature of Surgery/Treatment Given

Write: Medical management - IV fluids, analgesics, muscle relaxants, blood sugar monitoring and control

(No surgical procedure was done - it was medical treatment as ticked in B3)

C) Date of First Consultation (Prior to Hospitalization)

Write: The date the patient first visited for this injury before admission

If patient came directly to emergency and was admitted same day: Write 07/07/2026 (same as admission date)
Or write: Not applicable - direct emergency admission

D) Presenting Complaints of Patient During Admission

Already written as: GROUND LEVEL FALL INJURY, T2DM ✓ Better/more complete version to write: Pain in lower back, difficulty in walking, H/o fall on ground, known case of T2DM

E) Past Medical History

Already written as: T2DM ✓ Complete version: Type 2 Diabetes Mellitus - duration: __ years (mention how many years)

Also mention if on medication: On oral hypoglycemic agents / insulin
Attach past diabetic prescription/consultation papers

F) Was Patient Under Influence of Alcohol?

Already written: NO ✓ - Correct, keep as is.

G) Whether Present Ailment is a Complication of Pre-existing Disease?

Sub-field	What to Write
G) Main question	YES - T2DM patients have higher fall risk and poor healing
G-i) Specify disease	`Type 2 Diabetes Mellitus - associated with peripheral neuropathy causing balance issues and increased fall risk`
G-ii) Specify details	`Patient is a known T2DM case. Diabetic neuropathy may have contributed to the fall. Blood sugar was uncontrolled at admission.`

⚠️ This field is currently blank - it should be filled as the insurer will ask whether T2DM is related to the fall.

H) Whether Disease/Disorder is Congenital in Nature?

Write: NO

T2DM is acquired, not congenital
Fall injury is accidental, not congenital

I) Number of In-patient Beds in Hospital (Including ICU)

Write: The actual number of beds in your hospital (e.g., 50 or 100 - whatever is the actual count)

This is a hospital-specific detail - check your hospital's registration certificate for the exact number.

Quick Summary - Fill This in the Form

Row	Write This
A-i Primary Dx	Ground Level Fall - W18.30XA
A-ii Additional Dx	Type 2 Diabetes Mellitus - E11.9
A-iii Procedure	Not Applicable
B	Medical management - analgesics, muscle relaxants, diabetic care
C	07/07/2026 (direct emergency admission)
D	Pain lower back, H/o fall on ground, known T2DM
E	T2DM - since __ years, on medication (attach old prescriptions)
F	NO ✓
G	YES - T2DM with neuropathy, increased fall risk
G-i	Type 2 DM with peripheral neuropathy
G-ii	DM may have contributed to balance loss causing fall
H	NO
I	(Your hospital's total bed count)

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