RASHTRIYA SWASTHYA BIMA YOJANA

----------------------------------------------------------------Guidebook for Hospitals / Nursing Homes

Prepared by AMICUS ADVISORY SERVICES

Submitted to German Technical Cooperation (GTZ)

A Capacity Building initiative of Government of India

INDEX RSBY OVERVIEW 3 VALUE PROPOSITION FOR HOSPITALS ..3 KEY FEATURES OF RSBY ...4 HOSPITAL EMPANELMENT CRITERIA 12 RSBY EQUIPMENT ..14 TREATING PATIENTS UNDER RSBY .17 HELP DESK FUNCTIONS ..26 PAYMENTS FROM INSURER .28 SPREADING AWARENESS ..30 DOs & DONT s .31 FREQUENTLY ASKED QUESTIONS 32 ANNEXURES ..37

RASHTRIYA SWASTHYA BIMA YOJNA (RSBY)

OVERVIEW
RSBY was launched in 2008 by Ministry of Labor and Employment (MoLE), Government of India (GoI) to provide health insurance coverage for Below Poverty Line (BPL) families. The scheme provides for payment of expenses incurred by the families of the workers in the unorganized sector during hospitalization of family members. The Govt of India contributes 75% of the premium (90% for Jammu & Kashmir and North-Eastern states) in case of BPL families . The Ministry of Labor and Employment, Govt of India monitors implementation of the scheme across the country. The responsibility for implementation of the scheme rests with the States. As RSBY is an insurance-backed healthcare scheme, the states, through a transparent bidding process, select an insurance company to enroll the beneficiaries and to underwrite the hospitalization expenses for a year for an annual charge (premium). The state Governments contribute 25 % (10 % in the case of J&K and NE states). RSBY is a simple but unique insurance scheme which facilitates access to modern-day healthcare by the insured population through use of a technology platform and the basic features of the scheme are: Treatment in hospitals in close proximity to place of stay Requires payment of Rs. 30/- by a BPL family per annum as registration charges Allows families free access to hospitals both in the public and the private sector Gives the freedom to go to a hospital of choice Provides completely cashless treatment where beneficiary does not have to make any payment to empanelled hospitals in case of hospitalisation Identification of insured families through a smart card which carries photographs, names, age , sex and fingerprints of all family members on the basis of which they can seek treatment in empanelled hospitals Enables empanelled hospitals to seek payments directly from insurers within 28 days, that too preferably by electronic means Does away with the system of submission of documents by hospitals to the insurers.

RSBY : A VALUE PROPOSITION FOR HOSPITALS

1. RSBY is the biggest government-sponsored, health insurance initiative in the history of the country. Over 1.70 crore families across the country have already been insured under the scheme in the first two years itself. It is estimated that nearly 26 % of the population of the country in over 600 districts shall be brought under the fold of RSBY eventually. Mathematically speaking, about 30 crore lives shall be insured in the coming years. Going by a weighted average of incident rates in the rural and the urban India, nearly 5 % of the insured population i.e., 1.5 crore beneficiaries are expected to seek indoor healthcare in hospitals at the peak of RSBY momentum. Since RSBY encourages treatment in the public as well as the private hospitals, the scheme offers a huge opportunity to hospitals. RSBY has a distinct focus on villages / smaller towns, entailing greater demand for healthcare from such

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3. 4.

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locations. Every reason, therefore, for hospitals in smaller towns to participate in the RSBY movement. 7. Government hospitals too can charge for the indoor care provided by them to the insured population. RSBY shall be keen to see the revenue so generated deployed for upgrading the infrastructure and for providing newer, modern-day facilities in government hospitals. Should the state governments find it appropriate, part of such revenue can also be used for incentivizing health personnel in the government facilities.

KEY FEATURES OF RSBY

RSBY is a comprehensive, insurance-backed healthcare scheme which provides for coverage of hospitalization expenses incurred by the Below Poverty Line populace of the country. 1. Insurance Coverage a. RSBY provides hospitalization coverage for up to Rs. 30,000/- for a family of five on a floater basis. b. Transportation charges are also covered up to a maximum of Rs. 1,000/- with a limit of Rs. 100/- per hospitalization. The hospital which has provided the treatment will pay the transportation charges at the time of discharge. These transportation allowance are part of the Rs.30,000 insurance package. Registration Fees a. The beneficiary will have to pay Rs. 30/- at the time of enrollment and at subsequent renewals, as registration fee. b. This is to meet out the administrative expenses of the state government. This amount is paid to the insurer at the time of issuing smart card. c. As its a non-life insurance scheme, no money is returned at the end of the year even if services are not availed. Eligible beneficiaries a. Only those families whose names appear in the list provided by the State Govt. are eligible for enrolment under RSBY. b. Up to a maximum of five members of a family can be enrolled which includes husband, spouse and three dependents. c. Dependents can be children, parents or any other family member whose name appears in the BPL list. d. If the family has more than three dependents, the head of the household will have to decide which three dependents are to be insured. e. There is no age limit in RSBY and anybody can be enrolled if they are in the BPL list. f. The head of the household need to be insured at the beginning and dependents names can be added later also. g. All eligible families, enrolled in to the scheme, are issued an RSBY Card for identification. h. New born is covered from day one in the scheme. Hospitalization & Medical coverage a. Hospitalization means ADMISSION in hospital upon a written advice of medical practitioner for a minimum period of 24 hours.

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3.

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b.

However, it includes Day Care treatments/surgeries where 24 hours of hospitalization is not required 24 hour admission due to advancement in technology.

5.

Cashless Treatment a. RSBY provides that no payment is to be made by an insured person for treatment taken in a network-hospital up to the limit of sum insured. All medical bills are settled between a hospital and the insurance company. The insured person only has to produce the RSBY Card (Smart Card) at the hospital and to give the biometric thumb impression. b. For treatments in excess of the limit of sum insured and also for treatments excluded under the scheme, the insured person shall have to bear the expenses. The list of treatment and the cost are available on the website www.rsby.in. Empanelled Hospitals a. These are the hospitals empanelled by an insurance company in consultation with the State Government to provide cashless treatment to RSBY beneficiaries. The empanelment is done as per the standard empanelment guidelines of RSBY. Based on the ground realities, these guidelines may be relaxed by the State Govt. in special cases. b. The eligible beneficiaries are well-advised to take treatment in such network-hospitals as these hospitals are contracted to provide cashless treatment at pre-agreed charges. However, a beneficiary is free to take treatment in any hospital but he / she shall not be able to take benefit of cashless treatment and shall have to seek reimbursement of expenses directly from the insurance company. c. At the time of empanelling a hospital, the service provider of the Insurer would also install the necessary hardware and software as per RSBY guidelines. The cost of these would have to be borne by the private hospital. In case of Government hospitals, cost will be borne by the Government or the Insurance company depending on the conditions of the tender document. The hospital should also identify at least 2-3 persons with basic knowledge of operating a computer to understand the usage of these devices and the software. d. A Hospital Authority card is issued to every empanelled hospital, either by the Nodal agency or the Insurance company representative. This card authorizes transaction to be carried out at the hospital through the transaction software. Along with the Card the hospital is being provided with a PIN. The PIN protects the usage of card. The Hospital should delegate use of the card and the PIN to a responsible senior employee for safe custody of the card and to prevent its misuse. Package Rates The charges for medical/ surgical procedures/ interventions under the Benefit package, based on thorough market research, have been pre-determined. The state governments in consultation with all parties concerned fix the package charges for that particular year. The same can be amended with mutual consent for the next year. Provided that the beneficiary has sufficient insurance cover remaining at the time of seeking treatment, such listed package will not be subject to pre-authorization by the Insurer. Smart Card a. All eligible families, enrolled under RSBY, are issued a RSBY smart Card on yearly basis i.e. either a fresh card will be issued or an existing card will be renewed every year

6.

7.

8.

b. If required, one family can be issued two such cards, carrying details of two separate sets of insured persons, but the sums insured available for treatment under both cards shall total up to Rs. 30,000/only i.e., the overall limit per family. c. Smart Card enables identification of beneficiary primarily through fingerprints but if required through photograph, besides other information about a patient. The same can be read at the hospital using the installed devices, software and a computer (required in addition to the devices and software mentioned above). d. More importantly, it enables cashless transactions at empanelled hospitals and portability of benefits across the country. e. This card necessarily needs to be shown by an insured person at a network hospital before seeking treatment. f. It is advisable for the hospital to conduct an electronic transaction using the RSBY card at the following three times: i. First time is when the beneficiary comes to the hospital for Registration and at this time no money is blocked in the smart card ii. Second time on admission where the specified package is blocked and iii. Third time at the time of discharge (claim) to ensure that the claim of the hospital gets lodged with the insurer in time and timely payment of the same can be made. g. It is also mandatory for the hospital to transfer the data at least once in 24 hrs in the designated manner as explained during training. h. In case for any reason, the electronic payment cannot be made, the same should be informed to the District nodal person of the insurer immediately through SMS, fax or telephone citing the URN on the card and any other details as possible. i. It is also the responsibility of the hospital to inform the insurers district nodal officer in case the devices or software malfunction and either the transaction or data upload cannot be completed. j. A typical RSBY Card shall be as under.

9.

Pre-existing Diseases a. All Pre-existing diseases, unless specifically excluded, are covered under RSBY from the day one itself. b. Any disease that was present at any time in the past (including a disease which the insured person may not have been aware of) is termed as pre-existing.

10. Maternity benefits a. In case of smart cards issued from 1st April 2009, maternity benefits are covered. b. All expenses related to the delivery of the baby in the hospital are covered. c. Both normal and caesarean deliveries are covered under RSBY. d. A hospital will be paid Rs. 2,500 for normal and Rs. 4,500 for caesarean delivery.

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f.

A new-born is covered under RSBY since birth automatically for the remaining period of the health insurance policy even if the new-born is the sixth member. However at the time of renewal of the policy, the household will have to take a decision whether to include the new born for the following year. Expenses incurred in connection with voluntary medical termination of pregnancy are not covered except when induced by an accident or other medical emergencies to save the life of the mother.

11. Transportation Allowance Provision for transport allowance (actual with limit of Rs. 100 per hospitalization) subject to an annual ceiling of Rs. 1,000 shall be a part of the package. This will be paid by hospitals to the beneficiary at the time of discharge. 12. Pre and Post Hospitalization Pre and post hospitalization expenses up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates. These expenses can be in the form of medicines, diagnostic tests or consultation costs. 13. Food Charges Food only for the person who is hospitalized is covered in the package rate. Please note that it is mandatory to provide food to RSBY patients while admitted in the hospital. 14. Exclusions under RSBY a. Conditions that do not require hospitalization and can be treated under Out Patient Care. b. Expenses incurred at a Hospital or Nursing Home primarily for evaluation / diagnostic purposes only and expenses on vitamins and tonics etc unless forming part of treatment (hospitalization) for injury or disease as certified by the attending physician. c. Any dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure, filling of cavity, root canal including wear and tear etc. unless arising from disease or injury and which requires hospitalization for treatment. d. Congenital external diseases or defects or anomalies, Convalescence, general debility, run down condition or rest cure. However general debility arising out of malnutrition is covered under the scheme. e. Diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc. f. Sterility, any fertility, sub-fertility or assisted conception procedure, hormone replacement therapy, sex change or treatment which results from or is in any way related to sex change. g. Vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident). h. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials. i. Intentional self-injury/suicide, all psychiatric and psychosomatic and related disorders.

j.

Naturopathy, Homeopathy, Unani, Siddha, Ayurveda: Naturopathy, Homeopathy, Unani, Siddha, Ayurveda treatment, unproven procedure or treatment, experimental or alternative medicine including acupressure, acupuncture, magnetic and such other therapies etc. Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.

15. Basic Process Patient can be advised for hospitalization through hospital emergency or an OPD within or outside a hospital. b. Patient visits Helpdesk and produces RSBY card. c. Helpdesk verifies the patients details and registers him (by swiping the card on the POS machine and verifying fingerprints). d. If advised admission, a second transaction is conducted, i. By swiping the card ii. Verifying the beneficiary through fingerprint authentication iii. treatment code is selected from the package list and amount automatically blocked by the software iv. insurance company/ TPA get the intimation when the days transactions are uploaded thru the provided utility. e. In case for any reason, the transaction system is not working or the card cannot be authenticated, the insurers district representative should be called immediately and informed of the same. This is not a pre approval for admission but only an information of admission and nonworking of the electronic system. f. Treatment starts. g. Once treatment concludes, the pre-hospitalization and transportation allowance is paid to the patient. Also, post-hospitalization medication is dispensed. h. The patient is discharged from hospital and the claim transaction is conducted by swiping the card again and authenticating the fingerprint of the patient. This transaction when transferred to the insurers server as part of the days data transfer shall automatically and immediately raise the claim of the hospital on the insurer. i. In case the discharge entry is not electronically created, only the admission (blocking) entry shall not automatically raise a claim and the insurer would have to confirm treatment through any other means before admitting the claim entry and this may delay payment. j. Discharge summary and post hospitalization medication provided to patient, along with the details of expenses on treatment. k. All diagnostic and in-patient records to be maintained by the hospital. These do not have to be submitted to the Insurance Company, but the Insurance Company or a TPA can always review and/ or ask for the same at its own cost. l. The Insurance Company can also conduct random checks at hospitals, but these have to be limited to RSBY related facilities and patients only. m. Hospital to ensure that transaction report is sent to the central server by the end of the day through online data reporting system which is available in the transaction system. a.

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o. p.

In case of manual cashless approval (system failure, prolonged interruption in connectivity or non package treatment), hospital sends claim documents either in soft version or physical copy to the TPA/ insurer, preferably along with the RSBY card while the patient is still admitted. TPA/ Insurer processes claims transaction (or documents) as per transaction report for adherence to the scheme terms and conditions. Once processed and verified, payment is made to a hospital within 21 days by electronic transfer (or by cheque/ draft).

The process flow has also been explained with the help of charts in the ensuing pages.

Claims Process Flow Chart RSBY member visits helpdesk at a hospital

Card is swiped and authentication is done

OPD care required

IPD care required

Admission slip is issued

Referred to Helpdesk

Patient shows admission request slip

Package Treatment

Non-package Treatment

Medical Management

Surgical Management 10

Package Treatment
Helpdesk select package code based on l diagnosis

Single Disease

Multiple Diseases

Amount is blocked against the code

Separate amounts are blocked against each code

Information sent to Insurer / TPA by synching POS machine

Admission slip issued to the patient

Card kept with the hospital

Treatment starts Treatment Concludes

Final Amount is blocked

Authentication is done

Patient revisits Helpdesk

If treatment is not given

Discharge document s and card given to member

Process Closed

Amount to be unblocked and card returned to member

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Non Package Treatment Non Package Treatment Medical Management Surgical Management

Treatment Type

Cashless request is sent to TPA/ Insurer in prescribed format

Treatment in General Ward

Treatment in ICU

Once approval is received

Transaction details like disease, amount, and authorization letter no. updated on the card

Information sent to Insurer / TPA by syncing POS machine

Treatment starts

Patient revisits helpdesk

Treatment concludes

If treatment is not given

Authentication done and final amount is blocked

Amount to be unblocked and card returned to member

Member collects the discharge documents and card

Process Closed

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EMPANELMENT OF HOSPITALS UNDER RSBY

The BPL beneficiaries under the scheme shall have the option of choosing from a list of empanelled Providers for the purposes of seeking treatment. However those hospitals having adequate facilities and offering the services as stipulated in the guidelines will be empanelled after being inspected by qualified technical team and approved by the State Government/ nodal Agency. The criteria for empanelment of hospital are provided as follows: Criteria for Empanelment of Public Hospitals All Government hospitals (including Community Health Centers) and ESI hospitals can be empanelled provided they possess the following minimum facilities a. b. c. d. e. f. Telephone/Fax, Internet connectivity A Personal Computer Two smart card readers and A fingerprint verification machine or a standalone machine matching the given specifications. The facility should have an operational pharmacy and diagnostic services, or should be able to link with the same in close vicinity so as to provide cash less service to the patient. The diagnostic service should include testing of clinical specimens, X-rays and ECG etc.

Criteria for Empanelment of Private Providers The criteria for empanelling private hospitals and health facilities would be as follows: a. At least 10 inpatient medical beds for primary inpatient health care. The requirement of minimum number of beds can be reduced in consultation with the State Government/ Nodal Agency based on available infrastructure in rural areas. b. Fully equipped and engaged in providing Medical and/ or Surgical facilities. The facility should have an operational pharmacy and diagnostic services, or should be able to link with the same in close vicinity so as to provide cash less service to the patient. The diagnostic service should include testing of clinical specimens, X-rays and ECG etc. c. Those facilities undertaking surgical operations should have a fully equipped Operating Theatre of their own. d. Fully qualified doctors and nursing staff under its employment round the clock. e. Maintaining of necessary records as required and providing necessary records of the insured patient to the Insurer or his representative/Government/Nodal Agency as and when required. The list of documents to be kept at the hospital ends are: Copy of discharge summary Indoor case papers and OT records (which shall have daily treatment update) Final bill Copy of investigation reports Any other relevant document f. Registration with service Tax Department. g. Telephone/Fax, internet connectivity. Each hospital/health service provider shall posses a Personal Computer with 2 smart card readers and a fingerprint verification machine or a standalone machine matching the required specifications. These hardware and software will be procured through a vendor selected by either the Insurance Company/ TPA or SNA. The specification of the kit items would be-

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Internet connectivity Dedicated telephone/ fax line Computer should be capable of supporting all devices as mentioned above Optical biometric scanner for fingerprint verification as per specification mentioned below: o Thin optical sensor o Minimum 500 ppi @ 8bit per pixel o Active area: 13mm x 20mm o 1:1 search o Tunable false acceptance rate Smart card readers; 2 smart card reader (one each for hospital authority and beneficiary card) would be required with the following specification, o PCSC compliant o Read and write all microprocessor cards with T=0 and T=1 protocols

Other devices like printer, modem, etc may be required as per software. The same would be specified by the insurance company at the time of empanelling the hospital.

h. The Hospital should agree to the cost of packages for each identified medical/surgical intervention/procedures as approved under the scheme. These package rates will include Bed charges (General Ward), Nursing and Boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees etc, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances etc, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests and any other expense directly relate to the clinical treatment of the patient and food to patient . Expenses incurred for diagnostic test and medicines up to 1 day before the admission of the patient and cost of diagnostic test and medicines up to 5 days of the discharge from the hospital for the same ailment / surgery and transport expenses form part of package. The package also covers the entire cost of treatment of the patient from date of reporting to his/her discharge from hospital and 5 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient. .

Additional benefits to be provided by Hospitals In addition to the benefits mentioned above, both Public and Private Providers should be in a position to provide following additional benefits to the RSBY beneficiaries related to identify systems. a. b. c. Free OPD consultation. Fixed discounts on diagnostic tests and medical treatment required for beneficiaries even when hospitalization is not required. The Provider shall display clearly their status of being an empanelled provider of Rashtriya Swasthya Bima Yojana at their main gate and reception/admission desks along with the display and other materials supplied by the Insurer for the ease of beneficiaries, Government and Insurer. The Provider agrees to provide a help desk for providing the necessary assistance to the beneficiary Have at least two employees, during their period of empanelment, in the hospital trained in different aspects of RSBY and related hardware and software. The details of such employees should be provided to the Insurance company and State Nodal Agency. The Insurance Company shall arrange for Hospital authorization card for them and their training. Organizing at least one health camp each month in Villages. The schedule for the health camps will be designed jointly by Insurance Company and State Government/ Nodal Agency.

d. e.

f.

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Process for Empanelment of Hospitals The Insurance Company is primarily responsible for empanelment of hospitals and shall make sure that adequate number of both public and private providers shall be empanelled in a district. They shall also make efforts that the empanelled providers are spread to different blocks of the district. A District workshop for the health care providers (both public and private) shall be organized separately by the insurance company in each district to educate providers about the scheme. The State Government will on their part render all possible assistance viz. a. To give all necessary support for organizing sensitization program for the CHCs and Government Hospitals. b. Provide necessary support to the insurer in organizing separate district workshop for the health care providers in the district. c. To extend necessary support in providing space and other support for locating RSBY Help Desks at CHCs/other Government Hospitals which are empanelled with RSBY.

RSBY EQUIPMENT
Smart card A smart card is a plastic card about the size of a credit card, with an embedded microchip that stores a host of information and data. Once a BPL family is enrolled and is issued a RSBY card, the microchip in the card typically carries the name / age / sex / relationship / fingerprint impressions / photographs of all insured family members. a. At the time of hospitalization the card is swiped on the card-reader & fingerprints reader and all details of the patients come on the screen and matched. This enables a hospital to ensure that the patient is a bona fide beneficiary of RSBY and that the treatment costs therefore shall be reimbursed by the insurance company. Smart card also updates & stores details of all transactions which also confirms to a hospital as to what is the balance in the card which, in turn, confirms as to what extent a hospital would be reimbursed by the insurance company. A smart card is a safe instrument and cannot be duplicated. However, to use this card, the hospital should have a valid HAC (Hospital Authorisation card) issued by the proper authority along with the certified software from a service provider contracted by the Insurer or SNA

b.

c. d.

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Smart card reader Smart card is plugged into a reader, commonly referred to as a card terminal. When a smart card and the card reader come into contact, all details contained in smart card are displayed on the desktop, provided the reader is plugged into the computer. If the details do not match, no further processing takes place. On swiping the card at conclusion of treatment, the transactions get recorded in the card and the details already stored automatically get updated.

Fingerprints Reader Fingerprint reading is a method used to authenticate the identity of a beneficiary based on physiological characteristics. Having inserted the smart card in the smart card reader, a patient has to place his/ her fingers on the Fingerprints reader. If the fingerprint impressions at the time of admission match with those already stored in the smart card, the treatment is to progress. Similarly, the fingerprints need to be matched at the time of discharge of a patient from a hospital.

Hospital Authorization Card

Hospital Authority card is issued by DKM (District Key Manager). This card authorizes transactions to be carried out at the hospital. Along with the Card the hospital is provided with a PIN. The PIN ensures usage of the card by the authorized personnel only. Hospitals should delegate the use of this card to a responsible senior employee to prevent misuse and for safe custody.

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Desktop A general-purpose desktop which is capable to support all the devices being used in RSBY. It should have a monitor, key-board, mouse, data-storage facility and CPU.

Internet Connectivity: RSBY is a technology dependent scheme. All transactions under the scheme should be paperless. As a process, the details about hospitalization of a patient need to be transferred from hospital to central server of insurance company / TPA/ Nodal Agency. Internet connectivity is a must for the same. Transaction Software Though a hospital is not expected to have comprehensive knowledge of transaction software that is installed in the POS machine, it will be of help to have a basic knowledge thereof. Transaction software is primarily used for performing transactions using PC at the hospitals. It is a combination of all tools (Smart card, smart card reader, fingerprints reader and transaction software) which enables a hospital to identify & register a patient, bill for the treatment and receive payments for the same. Each beneficiary of RSBY will have a smart card with their details and also the details of their dependents. The card is inserted in the smart card reader and once the terminal reader identifies and authenticates a beneficiary by matching the authentication key and the fingerprints, the software allows the transaction to proceed further. The application will perform the below business functions: Enable the beneficiary to register for treatment. Enable the beneficiary to get cashless admission for treatment. Enable the beneficiary to confirm treatment charges using their smart card at the time of discharge.

There are four kind of transaction in transaction software. The same are:

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1.

Register: Register transaction is performed before the patient visit the medical practitioner. The transaction is performed Irrespective of whether the patient is treated on OPD/ IPD. This is just to ascertain the footfall of RSBY patient at the hospital level. Block: Block transaction is performed based on the provisional diagnosis and initial investigation at the time of admission. Hospital needs to select package and enter date of admission at the time of blocking the package amount on the card. Unblock: Unblock transaction is performed only in case there is a change in the provisional diagnosis or line of treatment or patient not treated. Claim: Claims transaction is performed at the time of patient is getting discharged.

2.

3.

4.

The above transactions are to be stored in the terminal and in turn are to be transferred to the Sever using dial-up connectivity at the end of every day.

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TREATING PATIENTS UNDER RSBY

Hospitals need to appreciate that RSBY is a totally cashless healthcare scheme and avoids all kinds of delays in providing treatment to the patients that are attributable to exchange of papers or system of authorizations between insurers and hospitals. All transactions, therefore, need to be carried out online as has been explained in this document. The only acceptable exemption to this rule are admissions which involve non-package treatment i.e., the treatments which do not find mention in the list of pre-agreed charges. It is also to be noted that the hardware used needs to be purchased from reputed vendors, which will be contracted by either the insurer/ TPA or SNA and must comply with the specifications mentioned in this document. As regards the transaction software, only those which are certified by MoLE can be used.
Step-wise listing and explanation of all activities that happen in a hospital from the time a patient walks into a hospital till he/she exits / discharged is as follows.

1) Patient can be admitted either through OPD ( in-house or external) or through emergency: a. In case of emergency, patient is first needs to be stabilized by maintaining ABC (Airway, Breathing and Circulation). b. In case of RTA / MLC ( Medico legal case ) need to be register and same needs to be informed within 24 hr of admission / Reporting of patient to the Hospital. 2) Patient/ Relative visits the helpdesk and shows the RSBY card 3) Verification and then registration of the patient is done at the helpdesk. Verification process involves the following activities. Patients verification is done by obtaining fingerprints impressions If the patient is not able to do the self verification then any member of the family who is part of the scheme can put his / her impressions and verification process can be completed III. The details of the insurance insurer, insurance cover available and policy period shall also be verified from the card through the software IV. The helpdesk attends the patient. a. If OPD, patient is referred to the OPD centre. All the expenses will be paid by member only. b. If IPD, patient is referred for the treatment and the expenses will be covered under the scheme. 4) If treatment requires IPD, patient is directed to the RSBY helpdesk for blocking the package code and charge. 5) If treatment of single disease a. Admission details are entered b. Package code is selected and blocked from the list already available on the POS machine. c. The admission slip issued and given to the patient. d. Once this is done, the patient is sent for treatment I. II.

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STEP-I

To be entered by hospital

STEP-II

Member card swiped

STEP-III

Authentication done

STEP-IV

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Member info and coverage details flash on screen

STEP-V

Claim registration

STEP- VI

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Treatment details to be entered

STEP-VII

Once entered, then it get saved automatically

STEP VIII: Patient referred for treatment

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5) If multiple diseases are to be treated and more than one package code needs to be selected a. b. c. d. e. Admission details are entered Packages are blocked as per the diagnosis of the patient. Hospital can select multiple packages based on the diagnosis. Step IV to VIII should be repeated for every new package / package code selection The admission slip/ block transaction slip is issued and given to the patient. Once this is done, the patient is sent for the treatment

6) Non-package Treatment: In case of the treatment which does not form part of the package list, following is to be done: a. For treatment related with Medical Management; i. If treatment is to be given by keeping the patient in ICU, the charge should be Rs. 1000/- day and will be automatically shown in the software ii. If treatment is to be given in normal ward, the charge should be Rs. 500/-day and will automatically shown in the software. iii. Please note that for the above treatment, the hospital needs to update the details on POS machine If patient is first admitted in ICU and thereafter moved to general ward, first ICU based amount is updated on the system and, on transfer to general ward, the additional amounts for treatment in general ward is to be updated. Finally, at the time of discharge, the actual amounts based on the number of days actually treated in both ICU and general ward are to be updated in the system. For Surgical treatment which is not a part of the package list, the insurer/ TPA are to be informed in the prescribed format and approval should be obtained before start of the treatment. The steps involve in the process are: I. II. III. IV. Pre-authorization request should be filled and sent to the TPA/ insurer. TPA shall review the request and revert back to hospital appropriately. Once approved, treatment can start immediately. All processes, as in other cases, are to be followed by hospital in this case too. a. The biometric card authentication should be done

b.

Card authentication and registration is to be done as mentioned at Point no-4 from Step- I to Step- VI
b. The Authorization letter number, disease details, treatment details and amount should be updated on the POS machine and on the card.

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V. If the TPA rejects request, all treatment expenses are to be borne by the patient only. 7) Un-blocking Transaction: In exceptional cases, if the treatment code has already been selected and charges have been blocked but the treatment has not been given or there is change in the package code, the process to be followed shall be as under. a. b. c. d. Card should be swiped and biometric authentication is to be done. Required changes (e.g., Treatment given: Y/N) are made on the screen and the same would be updated on the card as well. When the computer is connected online and data transfer module selected, the information reaches the central server/ TPA/ Insurer and details are automatically updated. For such cases no payment will be made to a hospital.

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8) AT the time of discharge: Once the treatment is concluded, the patient needs to visit the helpdesk again where the following activities take place. a. b. c. Card is swiped and authentication is done again. Date of discharge is automatically taken from the computer date and updated on the POS and card Helpdesk makes the payment of travel costs (Rs.100) and confirms on the screen

At the time of discharge

Patient visits helpdesk

Card swiped and Step-I to VI followed as mentioned at Point- 4

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Treatment and travel expense details to be updated finally

If any

26

Receipt given to patient

Patient is discharged

There may be instances, especially in the case of Emergency, where an ailment cannot be diagnosed immediately at the time of admission and may require further investigations and tests. In such a scenario a patient cannot be made to wait as also entry of admission details in the system cannot be kept pending. In all such cases, the code which represents the nearest diagnosis can be blocked. After receipt of all investigation reports if the code needs to be changed or multiple codes need to be blocked, the system permits a hospital to do that by following the above mentioned steps.

HELP DESK FUNCTIONS

Help desk is mainly to assist a RSBY card holder in completing required formalities & obtain treatment as also assist hospitals by facilitating POS machine transactions, selection of packages, and seeking authorizations whenever required.

1.

Check availability of card: Helpdesk coordinator is to ensure that the RSBY card is in the personal possession of the beneficiary or his family at the time of availing any RSBY related benefits. Without the card, the RSBY beneficiary cannot avail services available under RSBY. Guiding cardholder to a GP/Specialist within the hospital: Depending upon the type of ailment preliminarily reported a Helpdesk coordinator is to guide a patient to a doctor specializing in the treatment. In all other situations, a patient is to be referred to a General Practioner who, if required, shall refer the patient to a specialist. In case of OPD: If the ailment does not require hospitalization, Helpdesk coordinator will have to explain to the beneficiary that the RSBY card does not cover the OPD treatment. In case the hospital does not

2.

3.

27

provide free OPD treatment to RSBY card holders, any cost incurred for treatment under OPD will be necessarily borne by the patient. 4. In case of hospitalization: The coordinator will have to assist a patient by way of undernoted activities. a. Liaison with hospital for admission: Helpdesk coordinator is to ensure timely admission and availability of bed to a patient. Assist in verification process: This is one of the key duties of a Helpdesk coordinator to help a cardholder in the verification process and establish the identity of the patient. Fingerprints verification of patient by taking a patient to the reader and assisting them in giving live impressions. Verification of attendants details: In case the patient is not in a position to provide impressions of their fingerprints, the details of any other family member insured under the card could be verified to establish the identity of the patient. Malfunctioning of card: In an unlikely scenario of card becoming unreadable due to mishandling or other reasons, Helpdesk coordinator is to guide the cardholder to district kiosk for obtaining a duplicate card. In case of emergency, telephonic enquires can be made with TPA or district kiosk for more detail by quoting the details printed on the face of the card. This shall also entail that details of the attendant too are verified additionally.

b.

c.

d.

e.

5.

Help complete admission formalities: Helpdesk coordinator is to assist a patient in completion of other admission formalities stipulated by a hospital and arrange for allotment of bed, coordination with the treating doctor & investigation facilities. Explain if treatment cost is partially payable: In case a cardholder has availed treatment on the card previously and if the credit balance in the card at the time of admission into hospital is inadequate for carrying out the treatment, Helpdesk coordinator is to explain the situation to the patient or the attendant, as the case may be, and assist them in depositing the difference amount. In case the admission requires pre-authorization due to non-package surgeries or prolonged BCP, Helpdesk coordinator is to carry out the following activities. a. Preparation of pre-authorization request (carrying a note on the procedure and estimated costs)Annexure I Transmissions of pre-authorization request the same to TPA / Insurer by fax / e-mail / webupload. Liaise with TPA / Insurer and attending doctors for reply to clarifications sought Follow up for speedy authorization approvals by TPA / Insurer

6.

7.

b. c. d. 8.

Monitor and assist in non-medical issues: To assist a cardholder in the undernoted activities. a. Help locate facilities: The patient or the attendant may find it difficult to locate facilities like path labs, ultrasound, x-ray rooms etc. Helpdesk coordinator is to guide a patient / attendants in locating such facilities. Timeliness of treatment: The coordinator is to save a patient from unnecessary waiting in the hospital / facilities for treatment.

b.

28

c.

Ensuring availability of facilities free of charge: A major responsibility is to ensure that all the facilities that the RSBY cardholder requires are being rendered without charging any amount.

9.

Assist patient in discharge formalities: The coordinator is to assist a patient / attendant in discharge formalities which may be as follows. a. Fingerprints verification / attendants verification: Fingerprints verification is done twice, at the time of admission and at the time of discharge. Discharge summary: A discharge summary has to be made once billing is done. It is important that the coordinator checks all the aspects of discharge summary to ensure that all details are correctly mentioned and post-hospitalization medications prescribed. He is also to ensure that any charge made to the patient, if any, is in keeping with the terms & limitations of RSBY. Post-hospitalization medication: The coordinator is to translate to the patient / attendant as regards the medicines and care that one has to take post hospitalization and ensure that posthospitalization medication, if any, is provided by the hospital. A receipt with the details of amount claimed and blocked issued and given to patient.

b.

c.

d.

10. Reimbursement of expenses: Helpdesk coordinator is to ensure that all reimbursements, as under, that a cardholding patient is entitled to are provided. a. b. The expenses towards transportation of a patient to the tune of Rs. 100/- per hospitalization Pre-hospitalization expenses incurred by a patient if incurred outside of the hospital

11. Collection and transmission of claims documents to TPA / Insurer in cases of non-package surgeries and prolonged BCPs. Helpdesk coordinator should also coordinate with TPA / Insures and hospital for attending to requests for clarification and / or additional documentation.

PAYMENTS FROM INSURERS

Listing and explanation of all activities that a hospital does from the time a patient is admitted to the hospital up to getting his payment from insurers. V. VI. Conducting the Admission (blocking) transaction on admission Uploading transaction data on TPA / Insurer server:

Once patient gets discharged from the hospital, it is important that the hospital conducts the discharge transaction and also uploads the final transaction report on the central server. a) As per guideline the data transfer to the server should take place at least once in 24 hours. The exact timings or mode of transfer may be mutually agreed between the service provider and the hospital. b) For the hospital it is important to upload the data on regular basis as this ensures timely claim settlement.

29

2.

Payments from TPA / Insurer to Hospital I. II. If a claim is under the policy issued by the same insurer, the time taken to do the settlement should be maximum 21 days through electronic means. In case a claim is under the policy issued by previous/ different insurer (Inter-operability / Change of insurers), the following steps shall need to be taken. a. Claim documents to be sent by hospital to current TPA b. TPA will forward the same to the Nodal Agency of the appropriate insurer c. A copy of this information will be sent to district administration, SNA and the current insurer. d. Payment shall be released by the appropriate insurer to the hospital directly with the information sent to the current TPA, Insurer and SNA.

PROCESS FLOW 30

SPREADING AWARENESS
Awareness activities about availability of free treatment in hospitals under RSBY and Health camps are the main vehicles for sensitizing the beneficiaries of RSBY of latent ailments and consequences thereof if such ailments remain unattended for prolonged period. All Network Hospitals need to conduct regular free health camps. Common ailments can be attended to during such camps only and those serious in nature are to be referred for admission in hospital. Suggested awareness activity that may be undertaken by network hospitals

1.

Pamphlet Distribution

31

2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Public announcements / Munadi Playing of Audio-Visual media (Cassettes, Audio CDs and DVDs) Scroll in local cable networks News/Advertisements in local dailies Display of posters Display of banners Self Help Group meetings Village or Panchayat meetings Exhibits on hygiene, general health, prevention of communicable diseases etc. Exhibits on early detection and prevention of chronic diseases

Health Camps that may be organized by Network hospitals 1. Health camps may be organized at a frequency of at least once a month 2. It should be organized in areas of high concentration of RSBY cardholders 3. Typically a health camp may involve a. Routine pathological diagnosis b. Consultation for ailments c. Dispensing medicines there for d. Portable medical equipment can be used for effectiveness 4. Camp coordinator to ensure that the schedule is informed to all beneficiaries including peoples representatives. 5. The following documentation have to be done during the camp: a. Each patient has to be given an outpatient-cum-prescription card. b. Patients who require hospitalization should be given Referral card with the details of date for reporting to the hospital, place of appointment, name of consultant and mobile number of hospital coordinator or RSBY Helpdesk coordinator. c. Details of all outpatients and referred patients to be recorded by camp coordinators 6. The patients referred from the camps shall be followed up to report to the network hospital by the RSBY helpdesk coordinator for the specific hospital. 7. ?????? 8. Arrangement should be made to provide shade for waiting patients by erecting shamianas 9. Providing pedestal fans during summers 10. Seating arrangement for waiting patients 11. Drinking water for patients 12. Toilet facility for patients 13. Screening enclosures for patients On-site OPD Camps that may be organized by Network hospitals For ailments which are serious in nature and may require use of non-portable equipment for diagnostic purposes, hospitals may organize OPD camps in hospitals. Typically it is expected that the diseases which are common in the area of a hospitals outreach and occupational ailments are better diagnosed at such camps. Those requiring hospitalization, may be so advised on the spot.

Dos and DONTs

Hospitals are the key drivers of RSBY and represent the most import aspect of the scheme i.e., supply-side. The ability of RSBY to help poor access the modern-day healthcare is solely dependent on the conduct of hospitals. This section lists some basic expectations of a hospital.

32

Dos

Donts:

Always follow the standard guidelines i.e., standard medical guidelines and treatment protocol followed in India. Always follow the terms of an MOU agreed with a TPA/ insurer. Total transparency should be maintained with patients and TPA as regards the treatment details like diagnosis, treatment required, complications, costs etc. Always follow the standard RSBY processes & guidelines for package treatment, non package treatment and business continuity plan. In case of any deviation, TPA/ insurer should be informed in advance. Report misuse of RSBY card by a beneficiary immediately to TPA/ Insurer/ Nodal Agency Equip helpdesk with trained staff who can guide beneficiaries appropriately. Though payment of claims may not require submission of treatment documents, always maintain records for any future reference. Ensure that the standard hygiene is maintained at the hospital. Ensure that the travel expenses and pre-post expenses gets are to a claimant at the time of discharge from hospital. Ensure that the beneficiary is returned his / her RSBY card at the time of discharge. Ensure that only the cases which require the IPD treatment should be considered under the scheme.

Never get involved in false representation of any claim or any fraudulent activity directly or indirectly. Involvement of a hospital in such an activity would lead to not only its removal from the RSBY panel but also recovery of amounts paid and/ or legal action. The insurers may also wish to make such acts public which will, in turn, adversely affect the reputation of a hospital. Never attempt to convert OPD cases into IPD cases. Dont attempt to mobilize patients; the choice of a hospital is entirely that of a claimant. Never block a code other than for which treatment is to be given. In no circumstances, hospital should accept the requests as follows o Treatment of a non-entitled beneficiary on someone elses card. o Selection of multiple packages even if the same is not required o Blocking codes and amounts without actual admission and treatment. o Converting high-end OPD treatment to IPD

FREQUENTLY ASKED QUESTIONS

1. What is hospitalization? Under RSBY scheme, hospitalization applies to admission to hospital for 24 hours or more. However, it also includes such day care treatments which require less than 24 hours. 2. What is meant by day care surgeries?

33

Day care surgeries are the procedures which require a surgical intervention but patient need not be admitted to hospital after the surgery. A list of day care surgeries is provided below: Haemo-Dialysis Parenteral Chemotherapy Radiotherapy Eye Surgery Lithotripsy (kidney stone removal) Tonsillectomy D&C Dental surgery following an accident Surgery of Hydrocele Surgery of Prostrate Certain Gastrointestinal Surgeries Genital Surgery Surgery of Nose Surgery of Throat Surgery of Ear Surgery of Urinary System Treatment of fractures/dislocation (excluding hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization Laparoscopic therapeutic surgeries that can be done in day care Identified surgeries under General Anesthesia Any disease/procedure mutually agreed upon. 3. Are pre-existing diseases covered under RSBY? Unlike most health insurance policy which does not cover diseases that was present at any time in the past (including any disease, which the insured person may not have been aware of), RSBY covers preexisting diseases from day one itself. There is no discrimination with respect to the pre-existing diseases. 4. What is not covered?

RSBY does not cover OPD expenses, or expenses in hospitals which do not lead to hospitalization. Additionally, it also does not cover the ailments specifically excluded and mentioned in this document. 5. Is OPD Covered? OPD is not covered in RSBY. Therefore, medicines and tests which are not related or do not lead to hospitalization need to be paid by the beneficiary. 6. How are day care surgeries different from hospitalization of less than 24 hours? Hospitalization can be for both medical and surgical procedures. Therefore, in all the surgical cases, whether there is a need for hospitalization or can be handled on a day care basis, are covered. Also, medical procedures which need hospitalization for more than 24 hours are covered. 7. Are maternity benefits covered? Yes, maternity benefits are covered.

34

8.

What is covered under maternity expenses? All expenses related to the delivery of the baby in the hospital are covered and hospital will be reimbursed by the insurer

9. What all types of deliveries are covered?

Both normal and caesarean deliveries are covered under RSBY. A hospital will be paid Rs. 2500 for normal and 4500 for caesarean delivery. Ante Natal Care only 1 day and Post delivery 5 days treatment/ medication is covered

10. Is there any provision to take care of the new-born?

A new-born is covered under RSBY since birth automatically for the remaining period of the health insurance policy. 11. If there are five members already covered in a family under RSBY, will the new-born be covered? Yes. Even if the new-born is sixth member, he/she will be covered. 12. For how long will the new-born be covered? The new-born will be covered for the remaining RSBY policy period in which he/ she is born. However at the time of renewal of the policy, the household will have to take a decision whether to include the new born for the following year (provided the baby is included in the list. 13. Is there any provision for payment of transportation charges? Transportation charges are covered in RSBY. For every case of hospitalization, beneficiary is paid Rs. 100/as the transportation charge subject to a maximum of Rs. 1000/- during the policy period. 14. Is there any proof, like ticket etc. required claiming transportation charges? There is no proof required to claim transportation charges. 15. When will the beneficiary get the transportation charge, at the time of hospitalization or discharge? The beneficiary will be paid transportation charge at the time of discharge. 16. Who will give this Rs. 100/- at the time of discharge? The hospital which has provided the treatment will give this Rs. 100/- at the time of discharge to the beneficiary. 17. Is the food for family members also covered? Food only for the person who is hospitalized is covered in the package rate. 18. In case of any dispute arising between the beneficiary and the hospital, what would the grievance redressal mechanism be?

35

The parties shall refer such dispute to the redressal committee constituted at the District level under the chairmanship of concerned District magistrate and authorized representative of the insurance company as members. This committee will settle the dispute. If either of the parties is not satisfied with the decision, they can go to the State level committee which will be chaired by the Principal Secretary of the Nodal Department with representative of the Insurance Company and representative of the State Nodal Agency as members. 19. In case of any dispute arising between the Insurance Company and the hospital, what would the grievance redressal mechanism be? The parties shall refer such dispute to the redressal committee constituted at the District level under the chairmanship of concerned District magistrate, and authorized representative of the insurance company. If either of the parties is not satisfied with the decision, they can go to the State level committee which will be chaired by the Principal Secretary of the Nodal Department of with representative of the Insurance Company, representative of the health care providers and representative of the State Nodal Agency as members. 20. Who provides PoS machine The computer has to be provided by the hospital and the smart card related devices as well as software should be from the service provider contracted by either the insurer or the SNA. The cost of equipment is to be borne by the hospital only who is also the owner of these devices and software. 21. Who provides Transaction Software? Insurers or TPA arrange the transaction software from an approved vendor and upload the same. The cost of the software is to be borne by the hospital only. 22. What happens if there is some technical problem with PoS machine? Normally the vendors who install the equipment provide an Annual Maintenance Contract (AMC) also at extra cost. If a hospital has not opted for AMC, they have to address the problem on their own.

23.

What does a hospital do in case payments are not made by insurers within mandated 28 days? The hospital should approach to the district helpdesk centre (at kiosk) and lodge a complaint and expect resolution within 7days. If otherwise, they should approach the state head of insurers/ TPA. If all such efforts fail, they should bring the issue to the notice of the District Nodal Agency.

24.

In case there is a change of insurer, can a hospital continue to use old PoS machine. Yes, hospitals can continue to use the old POS machine.

25.

In case there is a change of insurer, can a hospital continue to use Transaction software provided by previous insurer? If new insurer is using the same software then only previous insurers software can be used. If otherwise, they should approach the new insurer.

36

26.

What recourse does a hospital have if there are unjustified deductions (even in case of pre-agreed package rates) or rejections of claims by insurers? Hospital should immediately write to insurers, TPA and District Nodal Agency and ask for an explanation. If no justification is available, insurers / TPA are contract-bound to make full payment.

27.

Is a hospital required to treat beneficiaries from other districts / states who may be insured by some other insurer? Yes, hospitals are required to treat insured persons from other states and also entertain treatment requests from beneficiaries who may have been issued RSBY cards by some other insurer.

28.

What does a hospital do if the credit balance in a card is less than the charges for carrying out treatment? Such amounts should be charged from the patient but the situation needs to be adequately explained to patient / attendants before start of the treatment.

29.

What if the treatment sought by a card holder falls under exclusions under RSBY? All such expenses shall have to be borne by the patient only. The situation should be explained to the patient / attendants before start of the treatment.

30.

What action an insurer or the Nodal Agency take in case a hospital indulges in malpractices? Such a hospital will be removed from RSBY panel and action against them under the laws of the land may be taken by insurer / TPA.

31.

If a hospital is empanelled under RSBY, is it free to offer treatment to the general public. Yes What happens if fingerprints dont match? In such a case any other family member insured under the card can also authenticate the patient. Post treatment, the card holder should be advised to visit a District kiosk for rectification. In case none of the fingerprints of the available members match, the hospital should immediately contact the district nodal person of the insurer for guidelines.

32.

33.

Can a hospital charge more than the package rates forming part of RSBY? No. RSBY is a paper-less scheme but are hospitals required to maintain usual records at their end. Yes. All medical records which hospitals are otherwise required to maintain, should be maintained.

34.

35.

Can the records at a hospitals end be audited by insurers or any other agency appointed by the Nodal Agency? Yes. Insurer or Nodal Agency will be well within their right to inspect records / documents relating to treatment.

36.

What in case software installed at hospital end is not accepting the PIN? 37

Interchange hospital and Beneficiary card. 37. What if finger print doesnt matches in the card? Refer the patients relative to District KIOSK. 38. Not able to upload the transaction on to the server? Check internet connection. Please check the modem cable and LAN cable. In case of USB modem please check that USB is fully inserted into the PORT. In case it still does not match then the service provider or the district kiosk should be informed immediately. 39. If the Transaction slips is not printed? Please check the printer cable, whether attached or Not. 40. What needs to be done in case of lost of HAC ? Please intimate to the insurance company and request for new card. 41. What need to be done if the hospital card is blocked? Hospital should be asked to get in touch with the insurer or the district kiosk.

Annexure I
38

AAA general Insurance Co. Ltd (IRDA License No. 00) Address ADMISSION REQUEST NOTE PART A- TO BE FILLED IN BY TREATING CONSULTANT Name: Shri/ Smt/Kum: ______________________________Age: ________yrs. Sex: ___________________ Patients Tel No. (Off) ______________ Fax (if any) _____________ Mobile no. _________________________ Resi. Tel __________ RSBY ID. No/ URN No: ____________________________

Name of Treating Doctor: ________________ Doctors Tel No: _____________________________________ Name of Hospital / Nursing Home: _____________________________________________________________ Presenting Complaints: ______________________________________________________________________ History of Presenting complaints:_______________________________________________________________ Duration of presenting complaints: _____________________________________________________________ Relevant Clinical Findings: ____________________________________________________________________ Relevant past history & treatment: _____________________________________________________________ Investigation Reports (attach separate sheet): -___________________________________________________ Provisional/Differential Diagnosis: _____________________________________________________________ Proposed Treatment Plan (attach separate sheet): ______________________________________________________ Particulars Yes/ No Since When Particulars Yes/ No Since When Hypertension IHD Osteoarthritis COPD/ Bronchial Asthama Any other Chronic Disorder Diabetes Heart Diseases (Date of First episode) Cancer Alcohol/Drug abuse Maternity cases: Gravida______Para_____Living _____LMP_____

In c/o Accidents, influence of alcohol / any other drugs: Yes / No

Whether MLC done: Yes / No

39

Particulars Date of admission Approximate expenses Room Rent Investigation Charges Name of Implant Cost of Implant

Details

Particulars Approximate duration of stay Class of accommodation Doctor / Surgeon Fees OT Charges/ Anesthesia/ Medicines Package Rate Total Amount

Details

PART B TO BE FILLED BY THE HOSPITAL AUTHORITIES AAA General Ins. Co. will not be held liable for the payment in the event of any discrepancy between the facts presented at the time of admission & in final documents submission. Signature & Stamp of Treating Doctor: _________________Rubber Stamp of Hospital & Signature ______________ PART C- TO BE FILLED UP BY THE INSURED I have No Objection to AAA general Ins. Co. Ltd obtaining details of my treatment / collecting documents and also hereby authorize PHS to pay the hospital bill & reimburse itself / receive the amount from my claim receivable from my insurance company. If my claim is rejected, I/we (the patient) will pay for the hospital & related expenses should this authorization become null & void due to wrong and/ or misleading and/or incorrect information regarding the duration of ailments and/or other historical information regarding my (patients) health status/. I acknowledge and agree that information provided by me are true and up to the best of my knowledge. SIGNATURE/S.: ___________________ Name: _____________________________________________

Annexure II
40

AAA General Insurance Co Ltd Address

Authorization Letter to the Hospital for the Treatment and Guarantee of Payment
To, ____________________________ ____________________________ Authorization No_________________ Date of Admission________________

We hereby authorize and guarantee for payment up to Rs _________________________________ (In Words) Rupees ________________________________for Admission/ Pre-Authorization request note sent by you dated__________ with the following information: Name of the patient_______________________________ UHID No____________ Policy No: ___________________

Class of Accommodation under______________ For Provisional Diagnosis ___________________ Authorized Length of Stay: _________ Days Previous Authorized Amount: Rs. _______________

Additional Amount Sanctioned: Rs.______________ Total Sanctioned Amount: Rs __________

Important Instructions to Hospitals:

If the hospital bill is estimated to be higher than the guarantee of payment, a request letter for additional amount needs to be sent to ICICI Lombard General Insurance If no further guarantee is available, the hospital must collect the excess amount directly from the beneficiary at the time of admission/ prior to discharge from the hospital, as per hospital rules and regulations. Charges for the following miscellaneous services and related allied services must be collected directly from the patient. i) Registration / admission charges ii) Ambulance charges(unless authorized) iii) Attendant / visitor pass charges iv) Special nursing charges not authorized by the attending doctor v) Service charges not forming a part of the bed charges in general ward, maintenance charges, surcharges vi)Charges for extra bed for attendant etc vii)Bed retaining charges viii)Charges for TV, Laundry etc ix) Telephone/Fax charges x) Food and Beverages for attendants and visitors xi) Toiletries etc xii) Purchase of medicines not related to the treatment xiii) Stationery, Xerox or certifying charges

41

For Billing- Please send the following as early as possible after discharge of the patient: o Hospital Bill summary with final bill, all interim bills with details of units of each service (Authenticated by patients signature) o o Discharge summary and reports of all investigations (original) All the copies of the Authorizations and communications during the Authorization sanction

Maternity benefits are given for first two children only(unless Authorized) Baby coverage charges to be collected from patient (unless Authorized) Valid for Admission within 15 days from issuance of this letter or expiry of the Insurance policy whichever is earlier?

Authorized signatory of AAA GIC Seal/Stamp of AAAGIC: Date______________________

Disclaimer: The cashless access in the network hospitals is merely a facility extended by AAGICL. It does not guarantee the availability, quality & outcome of the treatment. Undertaking by the Patient/ insured: I authorize the hospital/provider to submit all the original documents, investigation reports, bills, and medical information related to my treatment to AAAGIC

Signature of the Patient/Insured

Annexure III
42

RSBY Discharge Summary

Name of the patient Age Address Fathers name / Husband name Gender

Date of Admission

Date of discharge

Diagnosis Chief presenting complaints

Package code

OT notes

Hb /TLC /DLC ECG Ultrasound X- ray Treatment given

LFT KFT Lipid profile Others

Advice on discharge Name and signature of treating doctors Name of surgeon Name of Physician

43

Annexure IV

Patient Bill/ Invoice (Suggested) AAA Nursing Home Address Name of the Patient: Address: Contact Number: Date of admission: Total no of days: RSBY ID no: Date of Discharge Ward Category: Gender Age

Particular Name Package Code

Unit NA

Amount

Total Amount Tax ( if any) Total Payable amount Total payable amount in words:

Seal and signed of signatory

44